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MIPS 2019 – Summary of the Biggest Changes to the 2019 Final Rule (vs. 2018)
MIPS 2019 is here. It may seem too soon, as some clinicians are still finishing their reporting for the MIPS 2018 performance year. However, the time has come. The Quality performance category requires clinicians to report a full year’s worth of data. So, the sooner providers start, the better.
To help you get going quickly, we’ve summarized the biggest changes to the MIPS 2019 Final Rule, as compared to 2018.
As this is the third year of MIPS, the requirements have increased, along with the potential penalties. The CMS is raising the stakes, so to speak. However, clinicians can still avoid negative payment adjustments without too heavy a burden. While the demands have technically doubled for 2019, providers still only need to score 30 out of 100 possible points to escape penalty. That’s certainly doable.
Medical Billing Rates – What Prices to Expect for Specific Billing Services
The most common question medical billing companies hear: “What are your prices?”
It’s a perfectly reasonable question. Price is a major factor in any business decision. Plus, medical billing company rates aren’t exactly readily available—and when rates are listed, they are often vague or misleading.
In this article, we’ll clear up the confusion surrounding medical billing service rates. We’ll also break down what specific services to expect for a given price, along with the key factors that determine those rates.
Wondering what price you should expect for the specific billing services you need?
Background: What Has Led to Current Industry Rates?
Medical billing companies have existed for decades, but over the past 10 years, the industry’s business model has shifted dramatically. This change comes down to two main drivers:
1) Industry Growth
Growth in the medical billing industry stems from technological advances and regulatory changes—specifically, complex coding requirements (ICD-10), privacy regulations (HIPAA, HITECH Act), and expanded adoption of Electronic Health Records (EHR). As billing has grown more intricate, practice demand for third-party billing specialists has skyrocketed.
2) Consolidation
Like the broader healthcare sector, medical billing has experienced significant consolidation. Small, local billing companies once dominated the market. While still common, their market share decreased as large EHR software providers entered the billing space, attempting to automate revenue cycle management with bargain rates. While full automation largely failed, their entry permanently altered pricing expectations across the board.
The Effect: Growth and consolidation have created a more competitive, lower-cost market. While rates have dropped significantly from historical double-digit percentages, the challenge for practices today is ensuring they still receive the high level of service they expect.
Where do current medical billing prices stand?
The Simple Answer: Typical advertised rates range from 3% to 8% of collections.
The Real Answer: Modern pricing structure depends heavily on your practice volume, specialty, and the exact scope of services included.
Medical Billing Prices: The Reasons Behind the Wide Range
Medical billing pricing typically hinges on two key factors:
1) The Attributes of the Client
Practice characteristics heavily dictate quote variations. Certain client profiles require significantly more labor and specialized attention from a billing team. Below are the key attributes billing companies analyze:
In short, uniform workloads are easier to manage. A multi-state, multi-specialty practice interacts with dozens of payer rules and regulations, requiring a larger, highly experienced billing team. Consequently, multi-faceted practices reflect higher service rates.
2) The Specific Services Provided
Rates directly correspond to service scope. Companies charging 3% to 4.5% typically offer minimal, baseline processing (often offshored), leaving tasks like appeals, credentialing, and patient inquiries to your internal staff. Conversely, rates in the 6% to 8% range encompass comprehensive, end-to-end revenue cycle management.
Key considerations when evaluating service level:
- Do you require help with coding, claims appeals, credentialing, or patient collections?
- Does your practice need assistance with MIPS, HIPAA compliance, or pre-authorizations?
- Do you require dedicated, U.S.-based account managers for client communication?
- Are you retaining your existing EHR software or adopting a new system?
Core Revenue Cycle Services to Compare:
- Charge entry & claim submission
- Payment posting & Accounts Receivable (A/R) management
- Denial management & claims appeals
- Credentialing, enrollment & MIPS support
- Patient billing inquiries & data analytics
Average Medical Billing Rates: What to Expect
Based on our 15+ years in the RCM industry, rates align closely with the depth of support provided:
Average expected pricing tiers based on comprehensive vs. baseline billing service models.
Summary Takeaway: Bargain rates often mean hidden costs down the road in the form of unresolved claim denials or slow customer service. When negotiating with billing providers, align your decision with your practice’s operational goals: whether that means securing baseline claim processing or partnering with a full-service team that actively optimizes your revenue cycle.
Medicare Updates for the New Year: 2018 Fee Schedule, MIPS, and More
2018 Medicare Physician Fee Schedule
In November, the Centers for Medicare and Medicaid Services (CMS) finalized the 2018 Physician Fee Schedule. The most broadly relevant change is that to the payment Conversion Factor. The CMS has increased the payment rate by 0.41%. This change is the result of “the 0.5% update established under the Medicare Access and Chip Reauthorization Act (MACRA) of 2015, which has been reduced by 0.09% due to the misvalued code target recapture amount, required under the Achieving a Better Life Experience (ABLE) Act of 2014″.
