What You Need to Know About Fertility Billing Services Pricing Before You Sign

If you have a fertility clinic where your day to day work involves dealing with reproductive endocrinologists (REs), embryologists, andrologists or obstetrician-gynecologists(OB-GYNs); billing can be quite demanding. And with the various insurance plans, payers requirements, complex codes most of the fertility specialists look for services that can assist and resolve these issues. However, all these boil down to one ultimate question, which is the price.

What fertility billing costs depends on who you ask and the quotes rarely look alike. While some vendors send an hourly rate, some want a percentage of collections; a third can solely charge a flat monthly fee. Thus, rates are only comparable when the scope of work is similar. Moreover, each vendor may include a different scope of work. It can be based on an hourly rate, which might not include prior authorization. A percentage fee, which might reach collections you never meant it to cover, like self pay packages or old balances or a combination of both. This is why we are here to provide a guide for practices that plan to outsource fertility clinic billing and want to compare offers fairly.

What do fertility billing services include

A quoted rate alone cannot tell the whole story of what services are included. As with any facility, it mostly depends on whether you are buying the full fertility billing solution or just one of its operational processes. Nevertheless, a fertility clinic comes with its own hurdles of authorization tied to a particular cycle, package pricing and changing codes. So comparing rates side by side does not align here.

What does a comprehensive fertility billing service cover?

While the scope depends on the services offered by the fertility billing company, a typical RCM solution includes:

• Data management, eligibility and benefits verification, including fertility benefit limits
• Coding for its services In Vitro Fertilization & Laboratory Work or Global & Case Rates
• Prior authorization for cycles and procedures
• Charge capture and coding for retrieval, lab work, transfer, and storage
• Claim submission and payment posting
• Denial management and appeals
• Patient statements and self-pay balances
• Reporting on denials, clean claims, and accounts receivable

Related Reading: Reduce Claim Denials in Fertility Billing

Common pricing structures

As there is no standard agency with a rule, the charges entirely depend on vendor itself. They can either charge separate billing services or mix them and take a percentage or use one of the following pricing models below:

1. Hourly rate – It is when you pay on basis of the hours the vendor works for your account. So you further need to check if the charges are all inclusive, whether any kind of minimum charge or minimum hours is included. If any work is billed independently and how the vendor tracks the billable hours.
2. Dedicated resources – If an out-and-out member is assigned for the particular billing task and it mostly carries a monthly fee. Thus, you need to check if the particular fee is fixed or changes constantly with the workload and who will cover the work during any leave.
3. Flat monthly fee – With a fixed volume, you pay a fixed fee for a defined service. This is why you have to decide on the volume caps, any additional fees and services that are excluded.
4. Per-claim pricing – You pay a decided amount for each billable claim the vendor works on. Also, depending on the contract, it should be predefined whether it is an original submission, corrected claims, a claim line, and if additional claim-related work costs extra
5. Percentage-of-collections pricing – This is when a vendor charges a percentage of the collections. The contract should define collections, how refunds, reversals, and recoupments reduce them, plus the compliance review below.

The importance of reviewing every pricing model for compliance

Medicare has a separate rule for one situation: when it pays a billing and collection agent on a provider’s behalf. Under 42 CFR 424.73(b)(3), Medicare can make that payment only if the agent’s compensation is not related in any way to the dollar amounts billed or collected and not dependent upon the actual collection of payment. Section 424.80(b)(5) applies the same conditions to suppliers. Whether the rule affects you depends on what type of payments your practice, clinic or facility is choosing. Seeing Medicare patients doesn’t by itself rule out a percentage fee. Therefore, any fertility billing outsourcing agreement needs a careful contract review.

Understanding what in-house billing costs

To put an outsourced quote next to in-house billing, you first need a rough idea of what an employee costs dealing with a comprehensive billing service. For instance, the median hourly wage for a medical records specialist from last year for the month of May was $24.59, whereas wages as a share of total compensation in private health care and social assistance this June were 70.4%. So, the illustrative compensation estimate per hour is about $34.93 and illustrative annual compensation at the median wage is about $72,600. Then added with software, clearinghouse fee, training, recruiting, additional benefits etc cost further more.

However, outsourcing can cost considerably less than maintaining all of these. This is because an in-house team deals with hiring, training, employee benefits, software like Meditab etc to deal with which when outsourcing all these are eliminated. Here, your practice only pays an agreed fee for the billing support it needs so you can solely focus on patient care. So before hiring, one should ask each vendor the questions directly even if the answer turns out to be negative like:

• The Setup or onboarding fees
• Software, clearinghouse, and portal fees
• Charges for appeals, resubmissions, and corrected claims
• Patient statement and postage costs
• Minimum monthly hours or volume commitments
• Contract length, termination terms, and notice periods
• Who owns your data and reports if you leave

Along with additional operational questions like:

• How does the vendor track cycle-based benefit limits and authorizations?
• Does the vendor follow the requirements of an employer fertility-benefit administrator, where one applies?
• Who handles self-pay packages, deposits, refunds, and reconciliation?
• Does the quote include recurring cryostorage billing?
• Who bills separately for laboratory, anesthesia, and genetic testing services?
• Who is responsible for older accounts receivable?

Related Reading: Simplify frozen embryo transfer with fertility billing services

How SunKnowledge prices fertility billing

At SunKnowledge, we support reproductive endocrinology and IVF practices. Our services include but are not limited to charge capture, coding, electronic claims filing, denial management, prior authorization, insurance verification and billing for lab tests, anesthesia, cryopreservation, and cryostorage. In fact, we cater to other specialties and even offer complete virtual assistance services.

We have an all-inclusive rate of $7 per hour. Our terms further include no binding contracts and no write-offs or adjustments to claims without your consent.

In fact, the $7 rate is approximately 20% of the illustrative $34.93 estimate. That is just a comparison of two hourly numbers, not a savings figure. In fact, the case study below shows what the work produced for one client, where we have a fertility clinic with a recurring billing problem. Not only we have rebuilt the benefits questionnaire with fertility specific but added payer- validation checklist too. Additionally, we worked on all the aging claims in order of value. Also, the table below shows how our hourly rate has helped one of the clients save operational expenses by close to 80%.

Choosing a fertility billing partner

Choosing the right fertility billing partner starts with a simple understanding of how to get your fertility billing issue solved. Thus, an expert who has experience dealing with fertility benefit verification, prior authorization, cycle-specific coverage limits and insurance claims can be of great help. Additionally, a clear pricing and regular reporting add to the benefits. For clinics seeking dedicated support without the expense of expanding an internal team, we not only bring these priorities but also customized reports. Together, our fertility billing experts work towards a seamless workflow. Be it checking coverage to following up on unpaid claims, our team helps you address billing gaps that can hold up your payments for months. If you are someone struggling to manage complex fertility billing services, call our expert for a no-commitment call and see what difference we bring to the table.