billing company

International vs Domestic Coding Services – Myths, Pros and Cons

Outsourcing is one of the most significant strategic decisions that any firm has to undertake. It is seen as a way to reduce undue costs, improve growth, and put more focus on important things – hence enhancing the quality of service. For this reason, medical practices are adamant about outsourcing anything, which only puts unnecessary strain on their resources and affects their overall productivity.

Coding is crucial for the well-being of a practice – and any errors committed in coding can bring in losses and denied claims. Therefore, practices usually prefer outsourcing this arduous task to accredited coding services. However, selecting which service to opt for is the real question.

Here, we will discuss the myths that people, in general, have regarding coding services. We will also enlist the pros and cons of domestic coding services and international coding services.

The myths – debunked

  1. Data Security:

It is commonly believed that international coding services may not implement the requisite protocols of security, something which seasoned domestic coding services do. However, that is not true. Reputed international coding services also deploy the same SOPs of data safety, which are mandated by the US Government and honor all state and federal compliances.

  1. Proficiency:bill

Another misconception that people have is that international coding services are not proficient at coding and they may not fulfil the practice needs aptly. In fact, international coding services have a more comprehensive portfolio than that of domestic coding services and are more than capable of meeting the precise demands.

  1. Language Barrier:

Language barrier has always been an issue between native English speakers and those who use English as their second language. However, most international coding services deploy only those personnel who can effectively communicate in English. In this way, international coding services have effectively eliminated issues pertaining to the language barrier.

  1. Training Costs

People also feel that international coding services incur hefty costs while training their employees regarding domestic coding needs. That is not entirely true. In fact, domestic coding services can face higher training costs because of high employee payrolls. Overall, training costs are more or less the same for both coding services.

Pros of International Coding Services

  1. Serve a bigger audience:

International coding services serve customers from around the world and have more experience than domestic coding services. They have a broader understanding of the needs of clinical providers and can offer smarter and tailored solutions as per the specific requirements of the practice.

  1. Reasonably priced:

International coding services are usually better priced as compared to the domestic coding services. This is because international coding services are usually based in countries where pay scales are comparatively lower than that in the US. This reduces the overall cost of providing coding services.

Cons of International Coding Services

  1. No physical presence

The biggest drawback of international coding services is that many of them do not have any regional office in the US. This becomes a problem if a client wants to meet the representatives from that particular coding service in person.

  1. US laws may not apply on them

In general, international coding services take the utmost care when it comes to data safety. However, in the event of an unfortunate data breach, US laws may not be fully applicable to the responsible international coding service. A data breach caused by any domestic coding service may result in fines as high as $1.5 million per violation.[1] This might not be the case if the coding service is international. In fact, the provider will probably have no way to get compensated for the theft and misuse of protected health information (PHI).

  1. Issue of Time Zone Differences

International coding services are usually in an altogether different time zone and observe their own local holidays. In this way, a typical working day in US may be a local holiday in the native country of the international coding service. This can be a little problematic, especially if the provider has a serious coding problem, and he promptly needs to speak to the representative of the billing company.

  1. Implementation may take time

Due to geographical differences, international coding services may take time to implement their services. This is because they have to do everything virtually, from setting up their system to training their clients, which naturally takes more time as compared to doing things physically.

Pros of Domestic Coding Services

  1. Physically Present

Domestic coding services are physically present in the US. They have their regional offices where one-to-one meetings can also take place. Being physically present in the US, domestic coding services enjoy greater faith of the providers.

  1. Understand US Litigations Better

Domestic coding services usually understand the US litigations better than international coding services. Being physically in the country, they have a better view of their surroundings and usually respond to coding changes faster than their international counterparts.

  1. Faster Implementation

Domestic coding services usually offer fast-track implementation. This is because they specialize in only US coding and all their resources are focused on a single geographical domain. Being physically present allows such services to effectively interact with their clients, and understand their needs better, resulting in faster implementations.

  1. Follows Local Timings

Domestic coding services follow the US local time and observe only the US Holidays. Their representatives are available during the US working hours.

Cons of Domestic Coding Services

  1. Costlier

Domestic coding services are usually costlier. This is because the pay scales in the US are comparatively higher as compared to the developing countries, where the majority of international coding services thrive.

  1. Not geographically diverse

Domestic coding services do not serve practices outside the geographical barriers of the US. Such coding services are a little short on the overall experience of handling intricate coding problems, as compared to international coding services.

International vs Domestic Coding Services – In a nutshell

Parameter Domestic Coding Service International Coding Service
Understands US laws and jurisdictions better  Yes Sometimes
More Economical No Yes
More Geographical Experience No Yes
Faster implementation Yes No
Same time zone Yes No
Physical presence Yes Sometimes


Outsourcing medical billing company can be a tricky decision to take. If a provider is looking for a cost-effective solution, they can opt for an international coding service. On the other hand, if a provider wants to consider a coding service that only specializes in the US market, then they may go with the domestic coding services. In any case, it is always advisable to compare alternatives from both categories of coding services and then make an informed decision, with regards to the needs of the practice.


The Productivity Element

The Productivity aspect of exemplary patient care focuses on the services you offer to the marketplace, your patients. In healthcare, we provide our patient’s services. First, let’s examine what the service is. Service is combining together various materials, equipment, people, a fund of knowledge, and technology to create benefits for your customers or patients. These services include not only the benefits of what you do for them but the feelings your customer experience as they receive your services.

The Two Parts of Any Service

Any service can be thought to possess two separate parts – the outcome and the experience. The Productivity element concerns itself with the experience of the patient. The Performance element focuses on the outcomes of the service rendered to the customer.

With the Productivity part, there are a few things to consider as you develop your service. The first step is to know and understand the mission and purpose of your organization. What you do and why you do it will help guide you as you develop services for your customers. Once you understand the nature of your organizations work, your people and customer can they understand and appreciate what you provide.

Be Efficient

It doesn’t matter what service industry you’re participating in, your customers will spend time waiting. In healthcare, it’s simply part of the patient experience. Time spent waiting could be considered time wasted by your patients. The most common patient complaint about many of the physicians I’ve worked with is the perceived value the physician places on the patient’s time. In fact, I would argue many of us don’t value time as much as we should. Therefore, we should make the best use of our time and that time of our patients. Focusing on efficiency is how we will do that.

Read More: Key EHR Innovations to Improve Patient Experience

To be efficient requires you to understand the entirety of your process fully. You will need to understand each step, why it is there, and the purpose it serves. You will need to understand the order of the steps in the process. You will need to know where the chokepoints are and if they are flexible. Minimizing your patient’s wait time is the an excellent way to delight your patients.

Delight Your Patient

The patient experience is an essential part of the service you offer. It is important to design your services around the emotional response you want your patient to leave the clinic with. Spend some time thinking about how each phase of the process affects the emotional state of your patient. What emotions does each step invoke in your patient as they move through your processes? What emotional responses do you want them to experience? Once you’ve identified the desired emotions, you can design your processes to invoke those specific emotional responses.

Perhaps the most important facet of delighting your patients is their expectations of the experience. Their expectations help define the experience of your practice. Just as in a nice fancy restaurant or a movie, you walk into that business with expectations. Your patient does the same thing with your business.

You will want to help establish expectations for your patient. These expectations are set in part by sharing your mission and purpose with them. What you do and why you do it should be readily perceived by the patient from the moment they enter your practice as well as throughout the entire visit. Your people’s words, actions, behaviors, and attitudes should remind your patients of your mission and purpose. Furthermore, each step of the process of the patient experience has an objective that supports the mission and purpose.

There’s a big difference between delighting the patient and sucking up to them. Delighting the patient means you’ve met and exceeded the expectations you’ve helped establish at the beginning of the process. Sucking up to them is when you are just doing whatever the patient wants without regard to the benefit it provides the patient. It becomes easier to say no to a patient’s request when it does align with your mission and purpose if you’ve displayed your mission and purpose consistently throughout their visit. Saying no to a request that doesn’t support the mission and purpose will be easy and should come as no shock to the patient.

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Make It Easy on Your People

As you design processes, make the processes as easy as possible for your people. If steps in the process need to be rearranged, then do that. Frustrated employees are more apt to share their negative attitude with the patients, whether they know it or not. Everyone and everything should be united in the attitude and image of your organization’s projects.

Involve your people in the design of the processes as well. Most people want to do great work and if a step in the process hinders that, listen to them. If you’re hired great people, then you should have a plethora of good ideas. Avoid thinking they are merely trying to get out of work as they make suggestions. Remember they are attempting to be as efficient and productive as possible. If you know what you’re doing and understand the nature of your work, it will be easy to let your customers and your people understand this as well. Doing this is a huge step towards providing exemplary patient care.

The iBlueButton experience – Part I

During the course of the past few weeks, there has been some commotion and excitement in the healthcare community over the successful introduction of the mobile Blue Button. Many individuals within the industry are familiar with the concept of the Blue Button, however, since half of the clinician populace across the nation has not opted for EHRs, a large percentage of physicians are still oblivious to this common health IT terminology. Essentially, Blue Button is a tool which allows users of electronic medical records to obtain their personal health information via downloading it in various formats on their computers. It was initially designed as a platform to allow American Veterans easy access to their personal health information.

Blue Button has already been used extensively by hospitals throughout the country. Numerous federal agencies such as HHS (Health and Human Services), DOD (Department of Defense) and VA (Veterans Affairs) have applied Blue Button to facilitate their beneficiaries. The most basic format in which Blue Button allows the user to download their personal health information is a text file. By default the file downloaded from this technology is ASCII which is machine readable, meaning that the file may be downloaded in a variety of formats as required, such as text, PDF etc. As mentioned earlier, a Blue Button ASCII file is machine readable, which essentially means it can be parsed (broken down and analyzed) with a straightforward program on any basic computer. The downloaded text file may be accessed on any mobile device or computer without the need for any specific program. These files provide an effortless medium for transmitting health information amongst an assortment of members within the healthcare continuum.

Now, there is a new development in the world of health IT with regards to Blue Button, which is the iBlueButton mobile application. Humetrix is the health IT vendor which is responsible for shaking up the entire industry by introducing this revolutionary technology. Humetrix, a California based organization, revealed its iBlueButton 3.6 physician and consumer apps last October and won the national Blue Button ‘Mash Up’ Challenge. According to Todd Stein, the official spokesperson for Humetrix, thus far no one has been successful in making an application which makes a patient’s complete medical record accessible on their mobile device directly from their provider being solely under the patient’s control. As a result of this remarkable modernization, millions of military veterans and 37 million Medicare patients may now download their Blue Button medical record via their iPad or iPhone.

During a summit convened by the Bipartisan Policy Center in Washington DC, the National Coordinator for Health Information Technology (ONC) Dr. Farzad Mostashari was full of praise for the iBlueButton and its implication within the healthcare community. To quote, Dr Mostashari while sharing a personal story exclaimed that the iBlueButton “opened my eyes”. During a medical emergency pertaining to his father, Dr. Mostashari downloaded his father’s full medical record using the iBlueButton application. Upon obtaining the record, Dr. Mostashari shared it electronically with his father’s doctor who was astonished to see it, as this was unprecedented for him. Pleased with the resourcefulness of this app, Dr. Mostashari comments, “This is patient engagement at its best. This is the future of healthcare. I’m a doctor myself and when I first saw this, it was a real eye opener. I had first tried to download my father’s file from CMS’s Blue Button but it was everything I kind of feared – long, not pretty, it’s got all these codes that you don’t understand, the name of the provider is a number.”

Medical Device Interoperability

Medical devices are of paramount importance to patient care and well being such as the equipment used for clinical measurement, for instance x-ray imaging, temperature, blood pressure and critical life support. Although we depend heavily on modern medical equipment to treat patients, the devices used in practice are usually not interoperable and cannot connect with other devices. This inadvertently causes accidents which may easily be prevented through an interoperable network of devices.

In a traditional intensive care unit, patients are given treatment with the help of numerous devices such as ventilators, electrocardiographs and vital sign monitors. Most of the time, the manufacturers are different for each of these devices, which makes it harder for these devices to be integrated accordingly.

According to a report by the World Health Organization, there are approximately 1.5 million various medical devices in more than 10,000 different types of device groups available globally. These devices are instrumental for effective prevention, diagnosis, treatment and rehabilitation of diseases, and can be used in different settings such as clinics, hospitals and homes by patients, individuals and healthcare workers. They can also be integrated to a cloud Electronic Medical Records network which can make it easier for healthcare providers to record and monitor the performance of these devices.

Peter Pronovost, MD, Medical Director for the Center for Innovation in Quality Patient Care at John Hopkins University sheds some light on the reasons we need interconnected medical devices. “Medical devices need to share data, so that they can better inform clinicians and help patients,” said Mr. Pronovost. “By doing so, we can both improve quality and reduce costs.”

Similarly, a report by Deloitte states that 61% consumers are interested in using a medical device for checking their condition and electronically share that information with their healthcare providers through the use of technologies such as the EMR or Patient Portal.

Through the use of medical devices integrated with Electronic Medical Records, precious lives can be saved. For example, surgery procedures require surgical instruments and radiotherapy units are required to treat cancer patients. In the example of a cancer patient, an infusion pump giving pain medication to the patient can share and exchange data with the vital signs monitor to ensure that the patient is not being given a higher dose.

Joseph M. Smith, MD, Chief Medical and Science Officer of San Diego-based WHI said, “We see an enormous opportunity to use information technology and device innovation to bring about the much needed transformation in healthcare delivery.” He further added, “Today’s hospitals are filled with medical devices that are unable to share critical data, creating potential dangers to patients, as well as inefficiencies that put a tremendous financial burden on our healthcare system.”


RBRVS – A Primer

Any discussion of physician compensation tosses around RBRVS – Resource-based relative value scale – as if it is understood as readily as the time of day.  Yet few understand where and how this payment device originated.

RBRVS and their parent RVUs – relative value units – became the standard tool for Medicare reimbursement fee schedules in 1992 and have subsequently been adopted by the vast majority of insurance payers as their model, in one form or another.

Before 1992, physician compensation was based on historical charges physicians billed for their services, under a concept known as UCR – usual, customary, and reasonable.  Payers applied various statistical measures, such as the median charge; to set a single payment level for each service rendered. In the current discussion of RBRVS reimbursement, it is often forgotten that UCR was far from a satisfactory means of fixing payment rates.  Each payer interpreted UCR differently, so payments for the same service differed greatly, with no apparent rationale.  Besides being a source of complaint about physicians, and for patients who were often reimbursed far less than physician charges, UCR was equally problematic for the business community.  With health costs rising, UCR was viewed as inflationary as it relied on physician’s self-reported fees.  Medicare reported the real dollars spent on physician services per enrollee increased by 62.3% from 1980-86, while the number of enrollees increased only 12%.  The increase was half attributed to increasing physician fees and a half to the volume of services provided. This pattern of increasing costs of Medicare has continued unabated over the years.

Politically this was an unsustainable situation when coupled with growing problems of access as the gap in primary care access and specialist reimbursement widened.

Responding as Washington usually does, a commission was appointed, and the Physician Payment Review Commission was established in 1986 at the Harvard School of Public Health in cooperation with the AMA.  Their purpose was to develop a compensation system that was based on what inputs were required for each service, to build rationality into a non-system of physician compensation.

Initially, the study evaluated 12 major specialties, expanding use, and the CPT manual to assign relative values to each service, some 7,000 codes.

The three components of physician cost were considered the input into the development of a numerical value, an RVU for each CPT.

  1. Work expended by physicians by CPT code, including time spent before and after patient visits and procedures;
  2. Practice costs incurred in rendering services; and
  3. Opportunity costs of training or income foregone by physicians to obtain additional training

The Harvard/AMA researchers of the Commission surveyed 3,200 physicians, focusing on the work expended component of input.  Experts selected by each specialty society then scrutinized the survey results.  Finally, the investigators went to 120 individuals representing interested constituents – consumers, physicians, payers, and researchers – to critique both the findings and the methods.

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Reviewers found a high degree of reliability and validity in the survey.  A considerable amount of time was spent evaluating the work component of cognitive services, such as office visits because physicians in disparate specialties use the common codes in reporting these services.  The results independently obtained from thousands of physicians in multiple specialties differed less than 10 percent.  The RVUs were then extrapolated by the researchers to the related CPT codes.

The work component alone does not determine the RUVs.  That component is then modified for geographic variations based on the practice location and the malpractice costs, which also tend to follow a geographic spread.

The RVU is modified with a geographic practice cost index (GPCI).  This GPCI then is used to adjust the RVU for the location of the practice.  This to accommodate the urban/rural differences in the cost of practice operation.  A factor in this index is the geographic implications related to malpractice costs. The GPCI can significantly modify the total RVU.

None of these numbers is cast in concrete.  Annually the RVUs are adjusted based upon studies that seek to measure the changes in the work input of physicians for specific CPT codes.  The new technology that speeds up a procedure or reduces the technical skill necessary can be factored into the CPT code through changes to the RVU.

Similarly, the GPCI is also adjusted annually based on the indexes of the Urban Institute and Center for Health Economics Research

The three components RVUs – work, practice expense, and malpractice- combine to form the total RVU.

RVUs are non-monetary numerical values.  They represent the relative amount of physician work, resources, and expertise needed to provide services to patients.  The definitive payment for physician services results only when conversion factors (CFs) represented by specific dollar amounts are multiplied by specific RVU.  The formula is ($ fee) = CF ($) x RVU.

Understand that the RVUs by themselves do not determine the amount of payment.  For example, an office visit may have an RVU of 1.5.  Payer A applies a CF of $30 and pays $45.  Payer B applies a CF of $40 and pays $60 for the service.

Payers including Medicare choose a CF that they will apply to the RBRVS based on strategic and financial considerations.  This means that each payer is not valuing the services differently, but that they are determining to value all services differently.  To complicate matters further, payers are now choosing to assign differing CFs to specific ranges of CPT codes.  For example, the CF for radiology may be $20, while that of E&M codes is $40. Currently, there is a movement to curtail radiology, laboratory/pathology, restraint procedures, and increase the CFs for office visits.

The Medicare fee schedule comprised of RVU is called an RBRVS – resource-based relative value scale.

Since implementation in 1992, the RBRVS is updated annually, adjusting units for existing CPT codes and setting units for new ones.  While specialty society input is sought in the process, the ultimate decision is made by Medicare.

A reality of this annual review has continued a progression that devaluates procedural services and increases recognition of cognitive services.

The researchers, even in their initial findings and in the production of the RBRVS, recognized the criticism of their recommendations.  However, as there was a recognition that a perfect system was impossible, and the political winds precluded going backward.

Private insurance organizations, indemnity insurers, and HMOs moved rapidly to adopt if not the exact schedule, then a modified version of it.  The Medicare RBRVS schedule or an RBRVS schedule is believed to rationalize the fees that were allowed.  Too often the insurance organizations relied on historical trends, which resulted in high procedural fees at the expense of primary care, preventive and routine services.  Managed care re-introduced these services and repeated documentation supported the managed care notion that primary, preventive, and routine care would result in lower medical costs by early intervention and avoidance of greater severity of illness.  The question was how to properly pay for those services.  The long-term deterioration of primary care access was also believed to be the result of a financial payment model that devalued primary care.

Reliance of an RBRVS based on Medicare is consistently problematic for those CPT codes that are not generally reflected among the services that Medicare beneficiaries experience, such as obstetrical, preventive, and pediatric codes.  Similarly, any new service or one that Medicare does not reimburse is also generally problematic.  While there are codes for some of these services; their basis in Medicare data is generally very limited or based on the small sample by eligible beneficiaries, such as Medicare disability or ESRD.  Private carriers will either use the Medicare RBRVS fee, even if not reflective of the service, or will assign a fee to these codes.  Assignment of codes of new services can often lag significantly behind the usage within the industry.

The argument continues to this day, what is the proper balance between cognitive skills and procedural skills.

The RVU Formula

Total RVU = (RVU work x GPCI work) + (RVU practice expense x GPCI practice expense) +(RVU malpractice x GPCI malpractice)


RBRVS – resource-based relative value scale

A system of valuing physician services developed by researchers at Harvard School of Public Health and implement from Medicare in 1992.

RVU – relative value unit

A numerical value that depicts the amount of physician effort, risk, and resources for one service relative to all others.

CPT – current procedural terminology

A series of more than 7000 numerical codes each representing a unique physician service; most have established RVUs.

GPCI – geographic practice cost index

Numerical values that adjust each RVU component to account for geographic differences, primarily in practice cost and malpractice risk.

CF – conversion factor

A dollar amount multiplied by an RVU to calculate the total payment for a unique CPT code: Total payment = CF ($) x RVU.

No, you can’t hold medical information hostage for payment


Medical Record

Yes, lawyers can hold a client’s files until their bill is paid, such as the power of the attorney’s lobby, but refusing to provide medical records on behalf of a patient that owes you money is not a proper collection tactic.

From the standpoint of public policy, the belief is that medical care, and the information that is needed to provide that care trumps getting your outstanding bill paid.  Simple as that.


In fact, Federal regulations 45 CFR 164.524(c)(4) is very specific as to your right to charge an individual for a copay of their electronic health records, however, you cannot withhold or deny a patient a copy of access to that record on the grounds that they owe you money.  And in NY physicians are limited to a per page charge of $0.75 to make copies of that record.

Now the regulations that set the per-page price do not contemplate passing on the medical record in an electronic manner so the guidance would be to charge the cost of the media material and a nominal fee.  However, the regulations speak to providing the patient with a copay of the records, there is no provision that mandates that you pay for the cost of mailing or otherwise sending the records. 


Therefore, you may want to set up a policy that you will provide the records, but that they must be picked up by the patient or an authorized representative at your office, or that the patient provides you with a paid Federal Express or another secure delivery service.  You can invite the patient to either pick up the records, send the pre-paid delivery envelope, or pay the cost of such.  All should be received by your office prior providing.  Collecting the records by billing is unlikely.



Now if the patient says they cannot afford to pay for the records, you are entitled to ask for documentation of their financial hardship to then waive the cost.  In such incidences, keep your cost exposure to paper copies, no mailing, require to pick up.


Similarly, physicians have crossed a red line when they have not reported medical testing results to patients with outstanding balances.  There is an obligation of the physician, often delegated to staff to report test results.  Not only can test results not be held up due to outstanding balances, it is the practices obligation to contact the patient with the results, it cannot and should not pass that responsibility to the patient.  Yes, you can tell them when the results are in if they choose to call, but you have to reach out and present the results if they don’t.  And do so reasonably soon after receiving the results.  This is not only good for patient satisfaction but also good for patient care, especially if those results result in the recommendation for further care or testing.


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The unfortunate reality is that once medical services are provided there may be reduced interest by the patient in paying for them.  You are most at risk for non-payment on your commercial patients, where coverage and auditions, as well as nuances of approval and networks, is often confused.  Here you might want to consider contingent credit card authorizations to give you some cushion if the information you rely on from the payer as to coverage, deductible levels, and copays is less then accurate.

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Telemedicine – Adding a service and revenue to your practice

Physicians have long misunderstood the cost of an office visit.  Copays, generally not more than $20 seem like a limited disincentive to an office visit.  But the cost of an office visit was never just the copay, it includes the cost of the patient’s time, and hassle to schedule, the interruption their day, travel to and from an office visit of say 20 minutes.  To the patient, what are nearly 3 hours of their time worth? A complete morning or afternoon lost to a physician office visit.  And now add to that deductible, large deductibles.  All motivating patients to find a way to access care for less.

And patients are, the use and acceptance of urgent care centers continue to grow.  While studies show that most patient understands that the use of an urgent care center is episodic and that some even say they go because they don’t want to bother the physician when they are not really that sick, convenience is the greatest draw of the centers to patients. And now with most health plans providing coverage, convenience trumps continuity of care. Continue Reading