Medical claims business bullish on billing

YAKIMA, Wash. -- Bridgett Sammon is driven by money.

That is, the money of local doctors.

Sammon, who has been in the medical billing business for more than 12 years, believes that medical providers are leaving a lot of money on the table in unpaid insurance claims.

She cites a statistic from Medical Group Management Association, a national organization that provides training for medical practice administrators, that says medical providers nationally can lose up to 55 percent of outstanding claims more than 60 days old.

"Physicians just don't know," Sammon, 37, said. "Then they end up losing money."

That drive to improve the reimbursement rate drove Sammon to open her own medical billing business, Eclipse Provider Services Inc., out of her home in September. In April, she moved to an office at 1115 W. Lincoln Ave.

To establish her business practices, she drew from her previous medical billing experience working for nationwide companies such as DaVita and ACS Inc., as well as private medical practices such as Valley Nephrology & Hypertension in Renton. Locally, she worked for Memorial Practice Management.

She receives payment by charging a percentage of what she manages to collect for clients.

Sammon's key selling point to potential clients is a guarantee of payment within six months. If her company does not collect on a claim within that time period, she will pay the amount contracted between the provider and the insurance company.

It's a move that is considered financially risky in the industry, especially with factors out of a billing company's control that may leave claims unpaid.

But Sammon believes her venture can succeed on the promise of accountability.

"I'm not looking to make millions, I'm looking to make a difference," she said.

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Eclipse's arrival to the market comes as the third-party medical billing industry nationwide faces new challenges.

While the industry is undergoing consolidation and companies are getting larger, there is still plenty of potential market share.

According to the Medical Billing Management Association, a trade organization for third-party medical billing firms, its 600 members account for 30 percent of the claim payments made nationwide.

While part of the remaining 70 percent may include third-party companies who are not members of the organization, the association believes that most of the untapped market share is comprised of medical providers' in-house billing staffs.

With the Yakima Valley having more physicians and other medical providers to serve a growing demand for local health care, the need to outsource medical billing will likely grow as well, said Lashel Church, who heads the office administration program at Perry Technical Institute. She has more than 15 years of experience in medical administration.

"Physicians want to treat patients," she said. "Most physicians are compassionate people that care about the well-being of the people they're treating. The administrative part of it is something they don't want to deal with."

And while there are bigger and more established medical billing companies such as Memorial Practice Management and Valcare Billing Services, Church believes there still is room for new companies such as Eclipse Provider Services.

"I think there's definitely a market for a smaller, niche-oriented startup," she said. "When organizations get large and they've got 15 to 20 clinics they're trying to manage, some of the personal touch probably gets lost. I'm sure there are some smaller physicians (practices) that would feel more comfortable with someone they have a relationship with, which is easier to do with a smaller organization."

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Sammon is offering to help medical providers get reimbursement for claims that go unpaid for months. The money due is often owed by insurance companies.

Doctors also may be too busy with their practice to look closer into their medical billing situation, Sammon says.

Still, marketing to potential clients has been a challenge.

She's tried direct mail with little response. She's convinced her material often reaches in-house medical billing staff that don't want to lose their jobs if their doctor decides to go with a third-party vendor such as her company, so her informational packets get tossed in the garbage.

Sammon is looking to promote her company by holding a seminar for local medical providers on the risk denied and unpaid claims have on their bottom line.

She figures that once she is able to get into contact with potential clients and show how much money they are losing, they will begin to reconsider.

That's how she attracted her first -- and so far only -- client, an OB/GYN who was in Yakima and now is in California. Sammon organized a report that showed the provider had nearly $239,000 in unpaid insurance claims and patient balances, with some dated back to 2006.

As part of her pitch, Sammon offers an electronic health record system that would integrate with the practice management system her company uses for medical billing.

Under such a system, a physician could electronically document medical care for a patient. That documentation would then be sent directly to the practice management system for medical billing.

Sammon believes investing in that technology early on will make her more marketable.

"Physicians make a good living, but the problem is they're losing money in a lot of areas," she said. "If they're losing money, how are they going to have the funds to transition into the electronic age?"

* Contact Mai Hoang at 509-577-7685 or mhoang@yakimaherald.com.