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TEPR 2009: Verifying your outsourced medical transcription billing
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TEPR 2009: Verifying your outsourced medical transcription billing


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Do you know how you\'re being billed for outsourced medical transcription services? Do you know the different methods of counting billable units? This presentation details the variety of billing …

Do you know how you\'re being billed for outsourced medical transcription services? Do you know the different methods of counting billable units? This presentation details the variety of billing methods, how they can be manipulated and the importance of verifiability.

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  • 1. AlphaBest, llc Consulting & Transcription Outsourcing Transcription: Verifying Your Billing Statement
  • 2. Billable unit manipulation
    • No standard for billable units has ever been established in the industry. Standards have been recommended and white papers have been written
    • Standards or not, there is no method that cannot be manipulated
    • Reducing/eliminating billing unit fraud requires clear contract language and the ability to independently verify billable units for compliance
  • 3. Transcription Billing Units
    • Billing unit is a generic term: A billable unit can be any unit of measure agreed upon between the client and the vendor
      • Recorded minutes of dictation
      • Gross lines
      • Gross page
      • ASCII characters
      • Characters **
  • 4. Billing units: Recorded minutes
    • When the facility controls the dictation device, this is the most accurate and easily verifiable method.
    • Pros and cons:
      • Fast talkers and slow talkers
        • Responsibility is placed on the dictator to organize dictation
        • Transcriptionist is compensated for reduced productivity resulting from poor dictation habits
  • 5. Billable units: Gross Lines
    • This is a highly inaccurate and easily manipulated method of counting billable units
    • Predates digital era and software for automated counting of billable units
    • Pros and Cons:
      • Anything on a line is counted as a full line
      • Abuses include wider margins and larger fonts (vendors) and smaller margins and smaller or variable type fonts (clients)
      • Formatting for readability is sacrificed to increase (vendors) or decrease (clients) the number of billable units.
  • 6. Gross lines: Sample #1
  • 7. Gross lines: Sample #2
    • Sample #1: Large fixed font (14 pt), unnecessary paragraphs and indents, 1.5” margins (L&R): 13 lines
    • Sample #2: Variable width font, 11 pt, no paragraphs, 0.5” margins: 4 lines
  • 8. Billable units: Gross Page
    • A gross page is exactly what it sounds like: the number of printed pages (or page breaks in the word processor application) are counted. These may all be charged as whole pages; some vendors will calculate half, third and/or quarter page charges.
    • Pros and cons:
      • Electronic documents may not have traditional “pages.”
      • Can be manipulated much like gross lines to increase or decrease the amount of type on a page
  • 9. Billable units: ASCII characters
    • ASCII characters include most characters with the following exceptions: Formatting, such as bold, underline, italics, text boxes and printer instructions
    • ASCII is NOT a “keystrokes” method
    • Pros and Cons:
      • If there is an issue verifying charges for formatted characters, ASCII characters is a good alternative to other methods.
      • This method compensates for most of the characters required to produce a completed document.
  • 10. Billable units: Characters
    • Characters and character definitions have been at the core of every attempt to standardize
    • Character units include:
      • ASCII (previously discussed)
      • Characters divided by 65 (65-character line), sometimes erroneously referred to as the “AAMT line”
      • Visible black characters (VBC)
      • The only difference between the 65-character line, ASCII lines and the visible black character is the character units that are included in the metric.
  • 11. Billable units: Characters – divided by 65
    • When first defined by AHIMA, MTIA and AAMT (now AHDI), defined as:
      • “ ...the standard unit of measure for medical transcription shall be the character, which is defined as letters, numbers, symbols, and function keys necessary for the final appearance and content of a document, including, but not limited to, the space bar, carriage return, underscore, bold, and all characters contained within a macro, headers and footers.”
      • In reality, it doesn’t matter if the characters are divided by 65 to configure a “line.” It is only important to know the number of characters used in the division when making comparisons. Not dividing at all and using simply a character as a billable unit is more accurate.
  • 12. Billable units: Visible black characters (VBC)
    • A VBC is defined as:
      • “A character that can be seen with the naked eye. Under this counting scheme, spaces, carriage returns and hidden formatting instructions such as bolding, underline, text boxes, printer configurations, and spell checking are not counted in the total character count.”
  • 13. Billable units: Characters v. VBC
    • The AHIMA/MTIA Joint Task Force on Standards Development opined:
      • “The inclusion of nonprinting characters and formatting instructions makes it difficult to validate the line count of individual documents.”
    • The Joint Task Force’s conclusions are based on the assertion that verification of the billable units will take place manually, using the naked eye.
  • 14. Billable units: Character v. VBC
    • If a facility generates 10,000 pages of text and each page averages 1500 characters, even verifying 5% would mean counting 750,000 characters with the naked eye .
    • Software is available that can count and verify.
  • 15. Billable Units: Character manipulation
    • M = 1 visible black character. It can also be 2 characters.
    • m = 1 visible black character. It can also be 2 characters.
    • M = 1 visible black character. It can also be 3 characters.
    • Are these counting formatting instructions?
  • 16. Billable units: Characters continued
    • Even though the VBC isn't supposed to count format codes, it could be argued that the code itself isn't being counted. In the 65-character line, the format code toggle switches are counted once each; i.e.,
      • m = 3 characters (one for toggle on, one for the letter m, and one for toggle off).
    • For a single character, the 65-character method nets a higher character count. However, in the next example, any method counting each uppercase character as 2 characters and each bolded uppercase character as 3 nets a higher line count for the VBC.
  • 17. Billable units: Characters v. VBC
  • 18. Evaluating proposals from outsourcing services
    • The facility should set define the billable unit.
      • This makes it clear to vendors what they can expect in the contract
      • It makes it easier for the facility to compare proposals on equal ground
    • Vendors should be sent sample documents and price them as they would under the terms of a contract
    • Remember that price is only one factor.
  • 19. Contract language
    • Clearly define a billable unit!
      • There is no such thing as an AAMT line, an AHIMA line, a MTIA line or a “standard” line
      • There is also no such thing as a standard character
    • Don’t get carried away and mix up various methods. More is sometimes just more.
    • Only define the approved unit; nothing else is pertinent and it only creates confusion.
    • Do not let the vendor define the billable unit.
    • Require independent verification method
  • 20. Contract language: Example #1
    • “ Transcription work will be typed in pica style, 10 pitch, single spaced, with double-spacing between paragraphs. Margins will be set at one inch on both the right and left sides of the documents. A line with a minimum of 65 characters will be considered a line. Headers and footers on each report will not be counted in the line count for billing purposes.”
    • Is this gross lines or 65-character lines? The contracting agent didn’t know, either.
  • 21. Contract language: Example #2
    • We (finally!) come to realize this contract is for characters divided by 70 to define a line.
    • Character : Printable ASCII characters, including a single space, CR and LF. A space between words is counted as one ASCII character. Carriage returns to create blank lines are excluded.
    • Line Count : Gross Line is a line accommodating 70 characters. Lines of less than 70 characters shall be billed as a full line when meeting the following criteria: when completing a sentence, when part of an established format such as numbered diagnoses, discharge medications, etc., or when part of the typed demographic fields necessary to implement an upload of patient record into the EMR. Font will be Courier New 11 Point. Any line with typed text is counted as a billable line.
    • For billing purposes, lines are calculated by adding the number of characters in a report and dividing by 70.
  • 22. Contract language: Why it’s important
    • Vendors manipulate billable unit definitions to make their price per unit appear to be less than a competitor’s
    • Any method is acceptable as long as:
      • Contract compliance can be independently verified
      • Both parties fully disclose the terms and definitions and agree to them
  • 23. Verifying your invoices
    • Why wouldn’t you?
      • Time consuming
      • Lack of resources
      • Don’t know how
      • Trust in the system
    • Not verifying your invoices is like not checking time cards, your grocery store bill, your bank or credit card statement, etc. The cost can be significant.
  • 24. Verification: Independently verify invoices
    • Do not trust a platform or system that automates line counts for you
      • Most systems have “weighting” built into them
      • Any system can be built with duality; i.e., the parameters shown are as per the contract but the actual method used in the background may not use those parameters. Only independent verification would disclose this.
      • Disclaimer: I am in no way asserting or implying that everyone who uses a platform with automated line counts is taking advantage of these features
  • 25. Verification: Independently verify invoices
    • If your EMR has the capability of reporting units, use those units as the basis for the contract and the EMR reporting as the verification.
      • Only do this if the EMR setup is completely independent from the vendor
    • There are off-the-shelf, reasonably priced, fully configurable software programs that will count entire directories of documents in multiple formats (PDF, DOC, WPD, RTF, XLS, XML, etc.)
  • 26. Verification: Independently verify invoices
    • Expect a certain amount of discrepancy.
      • Not all software programs are 100% accurate and not all count the same
      • Determine what percentage discrepancy you would find acceptable
        • Determining the cause of the discrepancy (if possible) and correcting it will reduce the percentage of error
    • 500,000 lines/month @ 3% discrepancy =
    • 15,000 lines
    • 15,000 lines x $0.14/line = $2,100/month
  • 27. What is the least expensive option?
    • Gross lines @ 14 cpl
    • Characters @ $0.00277/char
    • 65 characters @ 18 cpl
    • VBC 65 character line @ 20 cpl
  • 28. Answer:
    • Gross lines: 8 x $0.14 = $1.12
    • Characters: 401 x $0.00277 = $1.11
    • 65 characters: 6.17 x $0.18 = $1.11
      • Caps 2 chars; bold on and off 1 char = 426 or $1.18
      • Caps 2 chars; bold 2 chars = 436 or $1.21
    • VBC 65 character line: 5.3 x $0.20 = $1.06
      • Caps 2 chars = 5.63 or $1.13
      • Caps 2 chars; bold 2 chars = 5.78 or $1.16
  • 29. by Contact me on the internet! Twitter: juliew8 LinkedIn: juliew8 Facebook: juliew8 Industry blog: