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July 22, 2009

Buyer Be Aware
By Lindsey Getz
For The Record
Vol. 21 No. 14 P. 16

Using the visible black character measurement standard can help ensure better billing practices—but it still requires a watchful eye.

It’s been a little more than two years since the AHIMA and the Medical Transcription Industry Association (MTIA) recommended the visual black character (VBC) method be used as the standard unit of measure for medical transcription. Based on research from the Joint Task Force on Standards Development, the announcement came in the form of a white paper that made quite a splash. Defining a VBC as a “character that can be seen with the naked eye,” this methodology does not count carriage returns, spaces, and hidden formatting such as bolding, underlining, text boxes, and printer configurations in the total character count.

Having a standard in place allows HIM departments to more clearly evaluate transcription services. It can also improve business relationships between providers and medical transcription service organizations (MTSOs) by fostering trust. “Since that recommendation was issued, my perception is that maybe 25% to 40% of new business opportunities have begun relying on the VBC method,” says Dale Kivi, MBA, director of business development for FutureNet Technologies Corporation, who has served on the MTIA Billing Methods Principles workgroup. “That’s certainly a huge jump compared to the use of that method prior to the release of their white paper, and I believe it’s continuing to grow.”

Still, some providers are showing resistance to adopting this new methodology. Kivi believes it may simply be a case of an unwillingness to change old habits. “The industry’s adoption of the VBC volume measurement standard is like converting to the metric system,” he says. “Even though many healthcare providers have started making the switch, many—especially in smaller facilities—simply prefer to continue operating with the measurement system they already know and are most comfortable with.”

And just because the VBC is recommended as the industry standard, it doesn’t mean there will be universal adoption. “There is no definitive body out there that says ‘Thou shalt bill the following way’ and everyone has to comply,” says Ethan H. Cohen, president of SPi Healthcare, a medical transcription solutions provider. “So you’re never going to get everyone billing the same way. There are people out there who still simply prefer other units of measure. As a company, we are strong advocates of VBC, but we do have some clients who request we not bill that way.”

While many companies such as SPi say they prefer that providers adopt the VBC method, Kivi suggests that a good deal of the resistance has come from transcriptionists themselves. “Whereas HIM directors have been coming up to speed on adopting VBC, the understanding and acceptance at the MT [medical transcriptionist] level has not progressed as rapidly,” he says. “Some transcriptionists are wary of changing because there have already been so many changes to their compensation. They see any change as something that could reduce their pay for the same volume of work. And because the VBC method eliminates payment for spaces, they worry it will eliminate something from their salary as well, which of course it does not.”

Billing Benefits
One of the most important benefits of converting to the VBC method is that it allows documents to be easily verifiable. With previous methods, there was room for improper billing practices to take place. “Think of it like a résumé,” suggests Betty Honkonen, CMT, immediate past president of the Association for Healthcare Documentation Integrity. “Someone could pad a résumé by adding in things that have no value, making the person look better than they really are. In the same way, with former measurement standards, a lot of unnecessary items could be added to a document and the provider could be taken advantage of. But the VBC method makes it harder for that to happen.”

Kivi agrees: “The VBC method is the only billing method that cannot be manipulated behind the scenes. Either a character can be seen on the page or it cannot, and that makes it easy to audit. Unfortunately [with previous methods], there were too many horror stories in our industry where, after further scrutiny, the applied billing calculations by some service vendors had been different than what was expected by the client. That being said, the vast majority of vendors do try their best to be totally transparent with billing.”

With VBCs, however, service vendors don’t have the opportunity to be vague about how they came up with a price. What’s on the page is what’s billed. “The VBC is a nice standardization because it eliminates any hidden costs, fees, or agendas,” says Cindy Vogt, transcription manager at Mary Hitchcock Memorial Hospital in Lebanon, N.H., part of Dartmouth-Hitchcock Medical Center. “With other measurements, there could be hidden costs contained within a document that were not easily visible—or maybe not visible at all. So by going with the VBC, it’s black on white. What you see is what you get.”

Another benefit of using VBCs is that they allow providers to better evaluate transcription services. With a standard in place, providers are able to compare vendors. “Using VBC allows the HIM directors to compare between various MTSOs,” says Honkonen. “With all of the other methods out there, it was impossible to compare, making it like looking at apples vs. oranges. But with a standard method, it’s finally like comparing apples to apples.”

For transcription managers, such an advantage can be a godsend. “VBC is especially helpful when working with multiple vendors,” notes Vogt, who says all Dartmouth-Hitchcock sites are using the TA+ Transcription Billing System from Arrendale Associates. “We’ve created a vendor report card where we score each vendor. It includes quality, cost, and turnaround time. Since we have no volume guarantees to our vendors, we always have the option to reallocate and redistribute work. If a vendor scores badly on our report card, they will receive less work from us. That’s been having a big impact.”

What to Watch For
Of course, nothing is ever 100% foolproof, and there are some bones of contention even when using VBCs. “Headers and footers are one issue,” says Cohen. “Some clients are OK with counting headers and footers across all pages, since they are visual characters, while others may insist on counting the first page only.”

Similarly, Cohen says that demographic information can also raise billing questions. “Demographic information typically appears in the report, but some service providers charge for it while some do not,” he says. “Our preferred method is to bill by the VBC and discuss with the client how they’d like us to handle headers, footers, and demographic information.”

Kivi agrees that it’s important for both parties to be clear about these types of details to avoid the perception that the transcription service is attempting to sneak something under the radar. In that regard, he considers communication to be a key to better billing. “Precisely define if, where, and when headers and footers will be counted,” advises Kivi. “Counting them once and counting them on the first page only are not always the same thing, as many templates allow for preprinted letterhead to be used on the first page only. In some cases, headers and footers are completely controlled by an EMR system that controls enterprisewide document access and distribution. In these cases, header and footer volumes should not be credited to the transcription service or technology ASP vendors, since they are not contributing to that volume.”

Kivi also says buyers should recognize that Microsoft Word does not consider any header and footer character volumes under its Tools menu bar calculations. Also, different versions of Microsoft Word can calculate slightly different VBC volume totals for the same electronic file. “Such discrepancies are typically only one or two characters for very large documents, but it does happen,” he says.

One way to make sure there are no surprises on the bill is to do your homework before hiring a vendor. “Provide some sample documents for the transcription company to transcribe and ask them to provide VBC counts on each document, then compare it with the VBC count you did yourself,” suggests Cohen. “That benefits both the provider and the transcription companies so that everyone understands what should be counted for billing. It’s not just the providers that want things clear up front. The transcription companies also want transparency and certainty on how much money they’re going to get for a job.”

Cohen recommends coming up with multiple-page sample reports that include headers, footers, and fictitious demographic information to determine how these items will be handled. “This allows both sides to be crystal clear on exactly what’s being counted and what the anticipated costs will be,” he says.

According to Vogt, Dartmouth-Hitchcock relies on sample reports to preview potential vendors. “We do samples whenever we interview vendors,” she says. “We give them each the same three documents, excluding PHI [protected health information], and ask them to tell us how many VBCs they counted. Most of the time, all the vendors come up with the same count, but if not, we are able to take a closer look and see what caused the differences.”

Once a vendor (or multiple vendors) is selected, a precise, easy-to-understand contract must be drawn up to help ensure proper billing. Phrases such as “all characters that contribute to the final look of the document” or “vendor calculations for volume are the only accepted/valid calculations for volume measurements” should be eliminated from all contracts, says Kivi. “These phrases leave the door open for creative interpretation of the intended counting methodology,” he says.

In an effort to eliminate any confusion, Dartmouth-Hitchcock’s vendor contracts actually define what the organization considers to be a VBC. The contract reads: “For purposes of the agreement, client defines VBC as follows: A visible black character is defined as any printed letter, number, symbol and/or punctuation mark excluding spaces, carriage returns and any/all formatting (eg, bold, underline, italics, table structure, text boxes, printer configurations and spell checking). All visible black characters can be seen with the naked eye as a mark regardless of whether viewed electronically or on a printed page.”

When it comes to headers, footers, and demographic information, there are no hard-and-fast rules. Dartmouth-Hitchcock treats these as negotiable items at the time of contract negotiations. “Some of our vendors charge for them and others do not,” says Vogt. “If they do charge, it is the same VBC rate as the rest of the report, and it is for the first page header and footers only.”

In addition, keep in mind that once a vendor is hired, the provider must still be diligent. After putting in all the effort to ensure proper billing practices, it simply doesn’t make sense to get lax once a vendor is selected. Unintentional overcharges are always a possibility, and it’s the provider’s job to be aware of potential errors. Notes Kivi: “After hiring a vendor, it all comes down to your own ability to audit and validate their counting on an ongoing method. It’s definitely not just a one-time thing.”

— Lindsey Getz is a freelance writer based in Royersford, Pa.

“The medical transcriptionist is the most frequently forgotten part of the healthcare documentation production chain.” Find out why at www.fortherecordmag.com/archives/ftr_072108p14.shtml