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Professional Service Agreement Time Sheet

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Professional Service Agreement Time Sheet Powered By Docstoc
					                    SERVICE AGREEMENT FOR
              ELECTRONIC MEDICAL BILLING SERVICES

This agreement is made between Accudata Service Inc (hereinafter called “Billing
Center”) and ________________ (hereinafter called “Client”) on this 5th day of August
2003.

WHEREAS, Billing Center offers electronic medical claims processing and billing
services to businesses in the health care industry, and whereas the Client wishes to realize
increased savings and efficiency through the use of the Billing Center’s electronic
medical billing services.

The parties hereto agree as follows:

FULL SERVICE BILLING (7% of receivables collected)
Billing Center will pick up billing information on a _________weekly schedule unless
other arrangements have been made and both parties have agreed. Billing Center will
process all insurance claims for the client for duration of this contract using the method
that in the judgment of the Billing Center provides the best and most efficient means of
recovering the reimbursements. Billing Center will process all patient bills. All claims
and bills will be processed within five business days, excluding those that contain errors.
Billing Center will maintain complete and accurate accounts receivable records for the
Client. The Billing Center will provide printed documentation of all activities on a
monthly basis, if client desires.

The Billing Center will provide follow-up and re-billing of claims that are not paid
because of errors in filing caused by omission(s) by the Billing Center. The Billing
Center will re-bill claims if the Client or the patient provides corrected information.
The Billing Center will at no time be responsible for errors made by the Client or a
representative of the Client or errors resulting from information provided by the Client
that results in billing errors.

The Billing Center will process up to one past due notification for patient responsible
balances, but will at no time act as a collection agent. Billing Center will advise Client of
overdue status, and recommend when collection procedures should be initiated. At the
Client’s request, Billing Center will process collection accounts at a rate of 25%.
Initial here is this service is requested. ___________.
Client will be notified of all accounts that are in collection status and will be given a
report on a monthly basis of those accounts when requested.

The Client will provide the Billing Center with all necessary information to facilitate the
processing of claims, (ie. Copies of patient records, demographic sheets, insurance cards,
physician notes, day sheets, etc.).

                    COMPENSATION PLANS (Please choose one)
_______COMPENSATION PLAN 1 (Full Service Billing)
Client agrees to pay Billing Center for the services described in the preceding section at
the rate of 7% of total receipts. Billing Center will invoice Client once a month, based on
the total receipts for the prior month, and will attach a complete report on the activity.
Remittance of these charges will be due in full within 15 days.

_______COMPENSATION PLAN 2 (Alternate Billing)
Client agrees to pay Billing Center for the services described in the preceding section at
the rate of $4.00 per claim processed. Billing Center will provide customer with aging
reports for follow up with carriers on past due accounts and patient balances.
Billing Center will invoice Client once a month, based on the total number of claims
transmitted or printed for the prior month, and will attach a complete report on the
activity. Remittance of these charges will be due in full within 15 days.

Billing Center will require a one-time non-refundable setup fee of $200.00. This
amount is due in full, at time of acceptance of contract.

TERM OF AGREEMENT:
This agreement will begin on ________________ and be in effect for a period of 1 year.
Contract will renew automatically unless either party provides written notification of
termination within 90 days of contract ending date. Either party may cancel the
agreement with 30 days written notification. Payment of 7% of collections will be
continued on claims filed during the period of the contract after the 30-day severance
period until all such accounts are paid.

INDEMNIFICATION OF BILLING CENTER:
Billing Center is engaged to participate as an independent contractor for the purposes of
claims reporting only. As such, Billing Center exercises no control or function in the
treatment of Client’s patients. Consequently, Client indemnifies and holds harmless
Billing Center from any liability related to the clinical practice of Client. Client hereby
indemnifies and holds harmless Billing Center from any liability related to the accuracy
or validity of any insurance billings and charges submitted by Client.

INDEMNIFICATION OF CLIENT:
Billing Center indemnifies and holds harmless Client from any liability arising from
inaccurate claims submitted when the data provided to Billing Center is accurate and
valid.

DEPARTURE FEE
Should the contract be terminated by the Client a departure fee of $ 200 will be charged
to cover the expense of backup and restore of all data to the Client’s computer system or
to another billing center if requested. A complete aging and account analysis may also be
provided at the Client’s request.


CODE OF ETHICS:
Billing Service maintains and operates under a Code of Ethics to insure the integrity and
confidentiality of Client and patients. A copy of this code is attached.
The parties hereto have executed this agreement as of the day and year first written
above.

                                                     Date_________________
Representative for Billing Center
Cindy Cook

                                                     Date_________________
Representative for Client
                       MEDICAL BILLING PROFESSIONALS
                              CODE OF ETHICS

Rule 1 - INTEGRITY AND OBJECTIVITY

In the performance of any professional service, we shall maintain objectivity and
integrity, shall be free of conflicts of interest, and shall never knowingly misrepresent
facts to our clients or the public.

Rule II - GENERAL STANDARDS

We shall comply with these standards:
       (a) Professional competence - Undertake only those professional services that
we can reasonably expect to be completed with professional competence.

       (b) Professional Due Care - Exercise due professional care in the performance of
professional services.

        (c) Professional Integrity - We will conduct our business with the highest degree
of integrity and in the best interest of our clients and the general public.

Rule III - CONFIDENTIALITY

We shall not disclose any confidential information unless directed to do so by the client.

Rule IV - FEES

Professional services shall be offered or rendered on a percentage basis whereby no fee
will be charged unless a specific result is obtained. The rate and means of billing shall be
made explicit.

Rule V - TRUTH IN ADVERTISING AND PROMOTION

We shall not seek to obtain clients by advertising or other forms of solicitation in a
manner that is in any way false, misleading or deceptive.
             Responsibilities of the Client for submission of billing data

New Patients
  • A new patient intake sheet with completed information (including all insurance
      policy information) must be sent to the Billing Center along with a copy (front
      and back) of the patient insurance card.

Existing Patients
   • A complete and legible superbill, fee slip or encounter form must be submitted
       with the proper diagnosis and CPT codes for the patient visit.

   •   All patient co payments or deductible payments must be clearly marked on the
       superbill with type of payment indicated. (Cash, check, etc.).

Insurance Payments
   • Explanation of benefits for all payments and denials received from insurance
      carriers.
   • Medicare EOB’s will be posted when the Client office receives checks from the
      carrier. Billing Center will notify Client when outstanding checks have not been
      reported as received.

				
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