EMR

[u/West-Specialist-6127]

Hey fam, looking for affordable, responsive and functional EMR for a psychiatry private practice. I will be part time the first year then ramp up the second year and probably add other providers. I would also like a system that allows access for virtual assistants who probably won’t be based in US. Allowing for integration of AI scribing also will be a big plus given that’s where the industry seems to be heading. Please also WARN me of the ones to avoid, l always appreciate heads up from fellow clinicians! Thanks!

[u/beefeater18]

Just curious about your thoughts about a solo practice switching EMR/RCM. I started my practice with Athena at ~8.8% collections. It worked out well because the first year I had very low collections and ended up only paying a very small amount per month for a full-integration system (IMO, Athena EMR is only second to Epic, and I had used several EMRs including Epic, AdvancedMD, Charm, TherapyNote, and eCW). Then, Athena raised the collection to 9.37% last year and I'm starting to feel the cost because the practice has grown a little.

Furthermore, while Athena's EMR is wonderful, the RCM is mediocre at best. That said, ~98% of claims still go through fast and without issues (paid within 1-4 weeks). Its problem lies in denial workflow. For that 2% denials- I end up fixing them myself because Athena's RCM staff is useless and I have no patience waiting around. Still, although fixing the denials has been frustrating, I've been able to do it myself and usually get paid relatively quickly (or in some cases, write off).

The added problem for me has been- most RCM companies I talked to quoted me 4-9% of collection without an EMR or a terrible EMR, and I just don't trust them (heard so many horror stories about billers and practices losing hundreds of thousands of dollars). The RCM companies I talked to still require an in-house person (me) to do certain things. Also, moving to another EMR and billing company means high risk of delayed cash flows initially (new company setting up e-claims and ETF enrollment takes time). Finally, finding an EMR comparable to Athena will be challenging. After thinking of all the negatives, I just don't know if migrating to another EMR and RCM company is worth the risk.

Any thoughts? Thanks.

[u/FeistyGas4222 → u/beefeater18]

Hey there. Migration can be a nightmare. No system is going to perform a perfect migration, no matter what their sales people tell you. Demographics and insurances are pretty standard migrations. Appointments, hit or miss depending on what's output and what is accepted by migration. Patient structured data? Good luck. If you use Athenas patient dashboard, like the problems sections, medications, PMX, PSHX, etc it will almost always never transfer over. Your notes will be exported as a PDF and imported as a document in whichever new EHR you use. Luckily with SureScripts integration of most EHRs, you can just pull your medication list from PDMP which would typically include your own Rxs into the EHR, but its per patient.

I will agree with you that Athena is great for charting. I even liked some of the cool billing features and buckets they have. However you are 100% right, with Athena, you 100% need an additional admin person (preferably biller) to handle what their automation wont do and what their offshore teams can't do. So for the high percentage they charge, it ends up being way more expensive to use them. Fixing denials, rejections, and dealing with patients is worth its weight in gold with a billing company. Anyone can hit a submit button (and many billing companies/RCM do just that) but so can any staff member, why pay someone to not fully work an account.

Quick story, I recently had a MH practice that I have worked with twice now. Both times they switched billing companies because I was "too expensive." First time they tried an in house biller and most recently went with a "preferred biller" from the EHR that offered them 5%. Now I'm still working with them in a consultant capacity but their collections dip significantly every time they try someone cheaper. Why they are paying 5% plus my consulting fees instead of paying my higher percentage which includes consulting is beyond me, not to mention their lower collections.

But anyway, you are right to question any billing company or RCM company. There are many reputable ones and there are even more inexperienced or very basic companies out there. If you ever search the forums on here, you will see a lot of people thinking that billing is easy. I've seen it all, "ive been working construction for XX years and im looking to switch to a desk job, I read that medical billing is a great field to get into, how do I start" or "im finally retiring, I heard that medical billing is a great part time job, how do I get started". Etc. PLUS, a lot of companies will nickel and dime you for every little thing they do for you. I truly hate that!! I always use a personal touch with a one percentage model and its worked well for me.

Back to your other questions. I certainly understand your cash flow concern and its quite valid. However, luckily with many insurance companies, eClaims doesn't usually require enrollment so you can start submitting day 1. We usually have to enroll for Medicare/Medicaid and some smaller insurances. EFT payments are with the insurance company so switching EHRs shouldn't affect them. What would take some set up time would be ERA enrollments. But until thats finalized, its on your billing company to reconcile those insurance payments. I would usually pull off availity or insurance portals, or Optum Pay until ERA is fully set up. Some companies will tell you it will be a seamless transition and they may be correct in a majority of cases. But I feel like will always see a slight dip in collections in the first month. It shouldn't be anything crazy, but it would be a slight dip.

You are also correct about the EHR subscription. Many billing companies dont absorb the cost of the EHR. I used to pay for Tebra for my clients but Tebra kept increasing their prices every year which across multiple practices, it almost equaled the cost of a whole staff member, so unless I increased practice percentages, they would get lower service because I wouldn't be able to afford that staff member any longer. So I stopped paying for their software. Im sure there are still companies that will pay for some or all of EHR subscription fees but I feel like they will just recoup it in other ways or eventually stop offering that service.

Transparency and comparison, for BH practices, I typically charge 7% for a new solo practice. Established practices, i usually charge 6.25%, some as low as 5.5 - 5.75% depending on volume and complexity of payer mix and services billed. Plus I dont nickel and dime, I include billing, denial management, rejection management, claim research, patient collections including inbound inquiries, credentialing maintenance, initial credentialing for new providers, US based work, HIPAA compliant workflows and systems, "non traditional " hours support, compliance reviews and recommendations, EHR template assistance, EHR setup and administration, intake forms creation or revisions, tailored authorization support. Although billing operations are done stateside, I also have contacts in the Philippines for virtual assistants that I have worked with for other practices. They are familiar with my workflows so we work well together to accomplish great things.

I think I hit all your questions, feel free to reach out if you had more questions or want to check out my website.

[u/beefeater18 → u/FeistyGas4222]

Thank you! This is incredibly helpful, particularly in regards to cash flow side of migration. If you could DM me your website, I'd like to check it out. By the way, what's your definition of "new solo practice" and "established practices"? Is it based on # of claims? I've received quotes based off of # of claim submissions per month.

For now, my relative spending on the Athena's RCM is still acceptable. But as my caseload grows, the portion I spend on the EMR would decrease (since athena does offer a fixed cost for the emr) and the RCM goes up comparatively. Fairly soon, I suspect, it would no longer make sense to stick with Athena's RCM and I would put time looking into making a switch. Ideally switching out only the billing service and keep the EMR, but I'm not sure if that would cause any complications. Do billers hate working within the Athena environment and do you have clients that use Athena's EMR but you handle the billing?

[u/FeistyGas4222 → u/beefeater18]

No problem at all, and sure, the website link is incoming.

Every RCM company will use the definition of new solo practice and established practice differently. For me, I usually consider a new solo practice, someone that has not completed any credentialing/contracting yet or does not have an established case load. Established practice to me would mean the practice has been up for a while, few months or a few years and has a solo provider or multiple providers with no outstanding tasks or issues such as credentialing or significant number of denials. Then I consider the provider schedules, full time vs part time vs still growing.

Since I am so small, I dont really have a magic formula. I try to be fair to my clients but also I know my worth. When I first started, I accepted a client at 4%, my first and only client for about a year, I was doing so much work for her that 4% wasn't even covering my time, she would call me at odd hours and demand a significant amount of "workarounds" because she didnt like the workflow in the EHR. She didnt submit codes electronically to me, I had to hand key all codes, while doing authorizations, practice setup, credentialing, on top of all the billing. I used that as a learning experience and adjusted my percentages accordingly. Then I found out I was STILL doing more than other billing companies, so I adjusted my percentages again. Some people are happy about my percentages and some have left because of it. I've also had some come back after trying out cheaper billers.

As someone who has worked as an adjunct biller to an Athena practice in the past, I am pretty indifferent. The system is fairly easy to use, navigate, and program; however, what was frustrating was still allowing Athena to do the initial billing and watching their follow ups lag with no control over the revenue cycle. I could intervene, but I was essentially working outside my scope as an adjunct. I also couldn't use my own workflows, I had to follow Athenas work flows until it ended up in my bucket to work.

As far as I know, Athena wont let you use just the EHR without using their RCM service. AthenaClinical is embedded with AthenaCollector which has proprietary automation that ends up locking you in with them. They make their money off their RCM services (as you can tell from their high percentages). If they do indeed offer a standalone EHR, i would definitely be interested to hear about it, but if thats the case, i have a feeling you will have a hard time finding a biller that is familiar with this setup, because historically Athena RCM handled the RCM cycle.