Athenahealth

So today, we’re chatting about athenahealth and how it’s used at your company. Before we jump into that, could you give a brief overview of the company and your role there?

Our medical group has around 100 providers, some employed and some contracted. Additionally, we have a staff of about 30 medical assistants. Our practice is completely virtual, meaning we don’t have any physical locations. We offer primary care, urgent care, and risk-adjustment services. My role within the team is to provide support from a practice administrative perspective. I manage all billing and revenue cycle management aspects, as well as provider operations, which includes tasks like staffing, credentialing, licensing, and general support for the providers in their day-to-day engagement with the practice. This involves looking after areas like benefits, salary information, and compensation. I also oversee the clinical assistant team, which consists of the medical assistants. Additionally, as a practice administrator, I act as a liaison to other departments, making sure the medical group has access to legal support, HR, strategic planning, and compliance.

How long has your company been using athenahealth?

About five years.

What was the need that drove you to look for a product like athenahealth?

We decided to build our own EMR system. However, our in-house EMR does not include the billing component necessary for billing CPT codes. We don’t have a clearinghouse or a form submission feature. This is why we decided to utilize athenahealth’s Revenue Cycle Management (RCM) feature and continue to use it today. When considering our options, we took into account factors such as the price point, the clearinghouse they use, and their ability to code and bill in different ways. For some of our integrated behavioral health services, we have a pay per-member-per-month (PMPM) billing system. This flexibility in billing and coding requirements was also a requirement for us as a practice. Additionally, we considered their support and reporting features. We want to have a cohesive and comprehensive financial reporting system that includes information on the claims we have submitted, the claims we have received back, denial rates, and adjustments, and we want to ensure that we’re submitting clean claims.

Which of their services are you using?

We’re only using the athenahealth RCM tool. I have a staff who handles the claims, and we have a certified coder on staff who reviews everything. Athenahealth is just a tool and clearinghouse for submitting claims.

Have you evaluated any other vendors, and what criteria were you looking for?

When we renewed the athenahealth contract recently, we also looked at Candid. We focused on how Candid could support our organization’s growth by enabling us to bill for complex services and using different billing codes giving us more control and flexibility of billing rules. We also considered how Candid could scale to meet the needs of our service lines and reduce manual work. We evaluated what tasks we currently do manually in athenahealth and whether Candid could automate them. Cost was another factor. Additionally, we explored the idea of using Candid’s certified coding services instead of employing a certified coder and adding that as a percentage of our revenue. We looked at flexibility, scalability, financial integrity, potential additional services, and the time and human cost of implementing a new tool.

How did athenahealth and Candid compare against each other?

Candid was definitely more flexible compared to athenahealth, which is a massive, corporate organization. As an example, athenahealth sets billing rules for all of its customers based on CMS guidelines. This means that if the rule doesn’t apply to us or we have specific exceptions, we would have to handle things manually, which is not ideal. Candid, being a smaller startup, had more flexibility in this area at the time to mirror its billing rules for that of the customer.

One appealing aspect of Candid was that they had certified coders which they charge as a percentage of claims. However, switching to a new service like Candid would require a significant tech and implementation lift. athenahealth, on the other hand, is an industry standard and well-known in the healthcare community. Our staff is familiar with it, and we even use athenahealth as an EMR backup. So reducing our dependency on athenahealth and relying solely on an RCM vendor would leave us without a backup solution for our EHR.

Ultimately, the cost of using and implementing Candid didn’t outweigh the benefits of their flexibility. Additionally, not all of our claims require the expertise of a certified coder, especially since some of our services are billed at a flat fee. So we didn’t prioritize the certified coders in our decision-making process.

I think smaller medical groups prefer working with smaller companies like Candid, possibly because they can’t afford the expense of athenahealth and don’t necessarily need the breadth of all of the function the RCM tool has. However, there is a level of unease in trusting a lesser-known company (in 2021-2022) to handle millions of dollars worth of claims processing per year, compared to trusting a company like athenahealth that has been in the industry for over 20 years.

How did the pricing compare?

Candid was more expensive than athenahealth because we included the certified coder component. So if we were going to switch from athenahealth, we would want to completely overhaul RCM. We’d want them to handle every aspect of it. We’d want to reduce our workload and rely on them more. But the price was relatively close when you accounted for the extra features that Candid offered, like $58,000 or $60,000. The main reason we didn’t choose Candid as an alternative was because the lift required to migrate would have been too high and the benefits did not outweigh those initial direct, and indirect, costs.

How was the sales process?

We did re-contract with athenahealth, and it was a really nice experience. Our sales representative seemed to have our best interests in mind. We originally had separate fees for clinical services and RCM services. The sales rep suggested that we switch to a per-encounter fee for clinical services instead of a per-provider fee, which resulted in a cost reduction of almost half. This wasn’t something I had thought of or requested, but she brought it to our attention. Since we don’t use the clinical side much, we opted for the $10 per-encounter option. It was a great cost-saving decision. We also didn’t realize there could have been a reduction in the clinical services contract. The sales process itself was quite simple, with a simple software agreement and terms of service.

Can you talk about onboarding and implementation?

We did consider implementing additional features beyond RCM, such as scheduling support, but ultimately chose not to. In terms of implementation, if you opt for white-glove implementation service, there will be additional fees and support. And the person handling this service is different from your customer account manager, which can make things a bit complicated. However, once the setup is complete, maintaining it is quite simple. We just update the fee schedule annually.

What use cases do you use athenahealth’s RCM product for?

Claims go from our clinical EMR into athenahealth through an interface that applies the CPT code and puts it into CMS 1500 form. From there, they go into one of three places. If there’s something wrong with the claim or they can’t attach a CPT code, it goes into a miscellaneous bucket for claims with issues. The interesting thing with athenahealth is that every claim has to have a checkmark indicating that you’ve verified the member’s eligibility. But in our case, since we see only patients whom we already know are eligible, this feature isn’t necessary. However, this is beneficial for larger groups who see numerous payer benefit plans. We have an outside company that goes into that bucket and verifies the eligibility for each person by manually clicking that checkbox. It’s an automatic click pushthrough that athenahealth requires, and there’s no option to turn it off. So we actually pay people to do that for us. That’s one of the downsides of working with a company like Athena that has standard billing rules applied to every customer, not truly customizable down to that level that other companies may do.

All urgent care claims go through automatically without a certified coder review. We simply submit the claim as it is with a press of a button. But for primary care claims, they go into a hold bucket for our certified coder to review. They make sure that the coding and documentation align properly. we’re using athenahealth for CPT codes, claim review, and submitting claims with the clearinghouse.

What are the strengths and weaknesses of the athenahealth platform?

I think the main strength of athenahealth is that it’s well-known. It does everything we need it to do. We have the option to manually process claims, but athenahealth also integrates with our clinical EMR, so the majority of our claims processing is automated. It keeps us updated with the latest rules and regulations, even ones we may not be aware of yet. For example, we didn’t know that the point of service for telemedicine had changed to 10 until our claims were put on hold because we were using the wrong POS. athenahealth helps us stay compliant with CMS billing guidelines, submission processes, and POS requirements.

In terms of usability, athenahealth is pretty straightforward and user-friendly. However, the challenge with athenahealth’s RCM piece arises if you have a company with complex billing nuances. It works well for standard medical group practices and fee-for-service billing, and it does offer PMPM and value-based options, but it’s not the best fit for a concierge practice or if you don’t strictly adhere to CMS billing guidelines (maybe customers do not bill Medicare/ Medicaid). . Additionally, the cost of athenahealth is quite high.. If we were a smaller standalone medical group, I’m not sure if it would be worth the investment. It has more features than we currently need.

Can you talk about building against their APIs and the development experience?

The API instructions are available, and I have access to them. They have given me the endpoints I need. Whenever I had questions about one of our APIs, they were able to give me the specific information I needed to troubleshoot any potential issues. Their APIs are very boilerplate.. I’m not sure how customizable they are if you want something different.

Which clearinghouse do you use? And is that integration built into the athenahealth product?

athenahealth handles the clearinghouse. They used to use Change Healthcare, but now have their own Clearinghouse.

How do you feel about their support?

It’s good. We have a customer account manager who we can contact via email whenever we have questions. They’re helpful when we need them, and they walk us through reports or help us pull different types of reports. We have no complaints on the level of service from our customer service account manager if we have questions.

Do you feel like you made the right call, going with athenahealth for your use case?

I can’t say about the initial purchase, but I’m happy we stuck with athenahealth versus switching to Candid when we renewed.

Can you think of any specific areas of growth for athenahealth and their product?

They excel at what they do, but they could be more adaptable for companies that don’t rely solely on fee-for-service and commercial payer reimbursement.

Do you have any general advice for someone who is going through the process of selecting an RCM right now?

It depends on what specific RCM process you’re seeking. If you need a front-end solution, or are looking for a certified coder, it’s important to thoroughly review all aspects related to the RCM. In my experience with athenahealth and Candid, we didn’t initially think about the cost of our staff and the external company we were outsourcing to. That significantly impacted our overall cost, and it can be either a positive or negative outcome depending on the circumstances. You should consider all touchpoints involved in the process.

Also, it’s important to think about the qualifications and certification of the coders employed by the company you’re interested in. You’ll want to know their service level agreement, response rate, and how effectively they communicate back to you. Do they promptly identify coding errors? Having a certified coder in-house has its advantages, as they can directly discuss any concerns with the providers. It becomes slightly more challenging when providers interact with third-party certified coders. It’s essential to understand the education requirements and communication channels for coding-related concerns, ensuring they align with your organization’s needs and that your providers are on board. Because without a good relationship between your providers and the certified coders, you may encounter difficulties.