But no longer. "Reimbursements have been steadily declining over the last three to five years," says Keith Solinsky, the COO of the Coker Group, a health care business consulting group based in Alpharetta, Georgia. In addition, says Vi Shaffer, a healthcare specialist with Gartner, an IT consulting firm headquartered in Stamford, Conn., "The rules are always changing, regulations are always shifting, and more complexity is being injected into billing." The term "billing" itself may be in jeopardy. A push both toward electronic medical records (EMR) and electronic medical systems (EMS), with a need to keep an increasingly close watch on the bottom line, now has many in the medical profession talking of "revenue cycle management" and "benchmarking."

These terms, which have long been floating around executive offices of big businesses, have become increasingly relevant to practices as office business managers and doctors are closely scrutinizing all aspects of their financial health.

Both Solinsky and Shaffer agree that in general, the billing industry, which includes those who make heavy-duty systems operated entirely on-site to application service providers (ASPs), who remotely provide complete automated billing services, is healthy. It's growing at a steady but unspectacular pace. The bad news for practices who need to change their billing operations that there are hundreds of vendors that offer solutions, but no simple way to separate out the top performers in each area. If only "Consumer Reports" could devote a couple of issues to the topic.

But there are some starting points to simplify the process for those considering change. There are three primary categories to choose from:

* Do the billing entirely in house;
* Outsource part of the billing process, and keep part of it in-house;
* Outsource billing completely, paying an ASP to oversee your practice's whole billing process, and perhaps your entire practice management system.

Because the federal government is pushing medical practices hard on the adoption of EMR systems, even the smallest practices, who understand that in the near future EMRs will be required, are reevaluating their entire systems. "If they have an in-house EMR, you would typically recommend an EMS in-house," says Solinsky. "You don't want to have one system inside and have to integrate the data with another system. So typically we recommend that practices go to a fully-integrated, single-database system." However, he concedes that some practices simply don't have the resources, either in terms of money or qualified personnel, to do this. In any case, Coker typically provides practitioners with five appropriate options in terms of billing systems, and leaves the final decision up to the practice.

What a quality billing system really comes down to, says Shaffer, is being on top of things from the start, which begins when a patient phones in to make an appointment. "That's when you start to gather information," she says. "And you make sure it's right. The name and address of the patient, the insurance information, the co-payments you need to collect up front, coding the claim correctly -- everything needs to be scrutinized. And when you don't get paid initially, you need to make sure you get either a good explanation or, if there is none, pursue payment again."

In a way, Shaffer contradicts herself -- while the industry practices are varied and bills can include many elements that make them appear complex, in reality practices and practitoners only deal with a small subset of the system. In any given specialty, collecting revenue may be a challenge, but it's not brain surgery.

Recently, Dr. Thomas Motyka, a private practitoner in North Carolina, moved his practice to new, larger premises, and in the process brought his billing system entirely in-house. With only one partner, this might seem both expensive and time-consuming, but Motyka says in many ways it's the opposite. He chose an in-house system because "You have control over it yourself. Nobody is more motivated to collect your money than you are." He added that he and his partner made their decision on whether -- or what -- to outsource based on a simple equation: does the percentage taken by an outside service amount to more than what it would cost to do it in-house? If so, do it yourself.

Billing "is not that complex," says Motyka. "It's a matter of putting the right numbers on a claim form, and the universe of information you have to understand within your specialty" isn't overwhelming either. Motyka said that his practice required nothing more than a powerful PC and software that cost a few thousand dollars and is intelligent enough to make sure claims are clean and complete before they're sent out and also that the codes make sense, and a business manager, who has many other responsibilities besides billing. The claims are filed electronically.

"I would rate in-house as preferable," he says. "Almost every doctor I talk to feels the same way. I've heard so many horror stories from people who've outsourced, and we have our own horror story, too."

Solinsky concurs with Motyka -- in-house systems need not be beyond the budget of most practices. While there are plenty of costly, powerful, high-end systems being produced by companies like GE and Misys, companies such as eClinicalWorks and Greenway Medical Technologies make systems that are affordable to smaller practices.

Ask around, says Shaffer. Figure out what constitutes success in billing for your type of practice, and aim to be very good, if not one of the best. Most important, she says, is what may be most obvious: "Get yourself a good model that works for you."