Subject: Rheumatology billing proposal: scope, drug payments, and terms

We are comparing billing companies for a rheumatology practice. Please send a written proposal based on this profile.

OUR PRACTICE
State and care setting: [fill in]
Clinicians and locations: [fill in]
EHR and practice management system: [fill in]
Services: [office visits / joint injections / infusions / other]
How we get drugs: [we buy and bill / a specialty pharmacy ships them / both / none]
Monthly collections for services, not counting drugs (approx.): [fill in]
Monthly payments for drugs we bought (approx.): [fill in]
Main payers: [fill in]
Work we want you to take over: [fill in]
Old unpaid claims or other handoff needs: [describe in general terms]

PRICE
1. What percentage or fee applies to service payments? What applies to drug payments, including J-code and Q-code claims? If drug payments are left out of your fee, please say so in writing.
2. Define what counts as "collections." How do you treat patient payments, refunds, payer take-backs, and money that comes in on claims filed before you started?
3. Is there a monthly minimum? Is it one combined minimum on the service and drug fees, or are there separate minimums? Which extra charges sit inside or outside it?
4. List every other charge: setup, data move, software, clearinghouse, patient statements, prior authorizations, credentialing, coding review, and work on old balances.
5. Show a sample monthly invoice using the two collection figures above.

WORK
6. Which tasks are yours and which stay with our staff? Please answer one by one: eligibility checks, prior authorizations, renewals, coding, claims, payment posting, denials, appeals, underpayments, patient billing.
7. Walk us through a made-up example of a weight-based infusion: units, NDC, the waste line and JW or JZ where applicable, and the administration codes. Use the clinician's prescribed and administered amounts.
8. How do you decide between the basic infusion codes and the complex administration codes for each biologic, for our Medicare contractor and each commercial payer?
9. How do you handle an office visit and a joint injection on the same day? Explain how you would estimate the effect of Medicare's proposed 2027 same-day payment change on our practice. Use a made-up example at this stage, without patient records.
10. How do you track, payer by payer, which drugs we buy and bill and which arrive from a specialty pharmacy?
11. Will you compare drug receipts with acquisition cost and check insurer payments against the applicable payment terms? Please report below-cost reimbursement and payer underpayments separately each month.

SYSTEMS, MONEY, AND REPORTS
12. Will you work inside our current system? What will we see directly? What changes if we leave?
13. Do insurance payments go straight to our bank account? How do you bill our state Medicaid program, given state rules on percentage fees?
14. What reports will we get, and how often? Can you show drug and service balances separately? How do you define each results number on your website?

CONTRACT AND HANDOFF
15. What are the term, renewal, notice to cancel, and exit charges? Do you charge on money that arrives after we leave?
16. How will you take over open claims, open appeals, and active authorizations? Who owns work from before the start date, and at what fee?
17. How do we get our data out, in what format, and at what cost?
18. Who will work our account, and where are they located? Do you use subcontractors?
19. Please send your service agreement, your business associate agreement, and two rheumatology references with a service mix like ours, including infusions if applicable.

If an item does not apply or you cannot answer it, please say so. We will treat anything left blank as unconfirmed until you answer in writing.

Please do not ask us for patient records at this stage. We will not send any.