Don't you just love the reality television shows where they come in, bulldoze someone's house, and a week later they have a beautiful mansion? The show lasts about an hour, and the house just seems to appear overnight.

What you don't see is the behind-the- scenes work—the sweat of 90 skilled craftsman working day and night to create this masterpiece. There is a lot of similarity between building your billing and reimbursement department and building your dream home. Both take hard work, sweat, and sometimes tears. But, most importantly, they both start with a solid foundation, and both are built with a plan in mind. A house built on unlevel ground will fail. A billing and reimbursement department staffed with the most productive and intelligent people, without a solid working process, will also fail.

With the American economy in such a dismal state, and unemployment on the rise, one would think finding people to staff your company would be an easy task, right? The reality is that it is hard to find educated and qualified individuals. Not only is it a difficult task to bring the appropriate people on, but how do you know you have the correct number of people? Staffing your reimbursement department and your company requires skill, tenacity, a positive attitude, and sometimes a little luck.

How do you know if you have the appropriate number of people in your billing department? There are many variables when determining the "magic" number of employees. Surveys have been done to determine revenues per FTE (full-time equivalent). But even with these surveys, it is hard to find a true benchmark. On average, HME companies need one biller for every $700,000 in revenue. However, this number can vary depending on certain criteria.

1. Automation within the billing department and throughout the company: The more automation within the company/department, the higher the revenue per biller. Auto-posting, denial management, document imaging, electronic claim submission, e-fax, and other operational enhancements improve efficiency. Using technology that is available today is key to operating not only your reimbursement department, but your entire company, with fewer FTEs.
2. The level of training and expertise of your staff: A well-trained biller can be responsible for a larger number of accounts. Your employee patient load does not have to be distributed equally. Your highly trained biller will be able to handle more patient accounts than one who is learning the ropes.
3. A well-trained intake team will decrease the number of denied claims, which frees up the biller's time to work more accounts. The training of your intake team directly affects the number of billers. If the billing staff is continually correcting mistakes of the intake team, or working claims that are denied due to inefficiencies at intake, then they will not be able to work an acceptable number of patient accounts.
4. Payor mix: The more payors with electronic billing, claim status, and electronic remittance capabilities, the greater the number of accounts that the biller can be assigned.
5. Product mix: If a significant portion of your revenue is represented by specialty product lines such as infusion and rehab, then the number of accounts that can be assigned to a biller will be reduced.
6. Days sales outstanding (DSO): Automation quickly impacts this number. If you bill claims electronically, your DSO will decrease. However, when evaluating DSO with regard to staffing, be sure to evaluate the level of experience of your billing team, the processes in place for handling claims, and the current level of automation prior to hiring additional employees.

In addition, your revenue per billing employee may be different based on how you define "billing employee." What constitutes a billing employee in your organization?

1. Are you considering only insurance billers and collectors as your billing team?
2. Is the medical documentation staff included?
3. Is the billing manager included?
4. Is the poster included?
5. Is QA included?
6. Are private pay billers included?

Typically, larger companies have well-defined job titles, whereas smaller companies have employees wearing multiple hats. Billing productivity numbers should be used as a gauge to determine the appropriate staffing ratio for your organization.

Sarah Hanna

We've discussed the variables when determining the number of employees within your reimbursement department. Now how do you find the perfect person to fit your organization? What is the secret formula to make that perfect employee/employer match? It would be nice to have an e-harmony or matchmakers.com for HME. But just like in dating, there is no fool-proof method.

Some companies hire recruiting firms. Just like a dating service, these firms weed out those individuals who don't match your needs or fit your company culture. They will bring you only the candidates they feel would be a good fit. However, even these experienced firms have sent some less than desirable candidates to companies for interviews.

Some HME companies use personality tests. Others use relational references ... a friend or family member of a friend or current worker. Others use gut instinct, while others say, "Heck, you can walk, talk, and chew gum at the same time. You're hired!" I don't subscribe to the chewing gum method, but sometimes it feels like that is our only option.

But let's face it; applicants are normally those without experience in HME billing. So we have to look for applicants who possess the characteristics needed for the open position, and understand that they will need to be trained.

One major mistake is believing that if applicants have medical billing experience, or hold a certificate in medical billing, they don't need training. Applicants who have physician, skilled nursing facility, hospital, and billing experience still require training. Providers must have a well-defined training process in place to meet optimal FTE staffing requirements. Without it, the number is just a number.

Start with a well-defined job description, but leave room for flexibility. Outline daily, weekly, and monthly duties (as applicable) and review the training program with the employee. And, of course, document all training.

Having a billing and medical documentation manual (that is continually updated) is a key element in guiding your new hire. The manual is the textbook, the trainer is the professor. Trainers need to understand how the trainee best learns. Does the trainee learn better via observation, or by actually performing the task at hand? Determining which technique is best for your new employee will determine how fast they become a revenue-generating team member. Revenue generating means bringing money into the corporate checking account.

ON THE WEB To find more articles, visit our free archives section. Our convenient archives require no log-on or fee. Find helpful articles such as: March 2008 New Era, New Opportunities By Tor Valenza. Home sleep testing and transportation industries (trucking, parcel delivery) combine for massive CPAP potential. July 2008 Technology Guru By Rich Smith. When it comes to software, Irene Magee has seen it all.

When taking on the role of "professor," patience truly is a virtue. Employees need to understand the process of their training, and the expectations of the trainer. Once new employees are on their own, they will undoubtedly have questions. Trainers must be accessible to new employees and be patient. To ease the burden on trainers, explain how questions need to be handled so that they are not constantly being interrupted throughout the day.

It takes approximately 1 year to become a "seasoned" biller. However, HME billing is a never-ending learning experience. There truly isn't a "billing guru." Great billing employees are excited about their jobs and continually willing to learn changes in reimbursement policy and regulations. They take their knowledge and can put it into practical terms. They consistently look for ways to become more efficient, and don't settle into a rut.

A solid foundation and a great plan will eventually lead to success and peace of mind. Ultimately, you will be able to withstand the storms and bad environment that any government or commercial payor can launch at you.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting Inc, Tiffin, Ohio. She can be reached via e-mail: .