A healthcare BPO (business process outsourcing) company is an outsourcing vendor that works on the operational work for a healthcare organization. This usually spans a variety of tasks, including patient access, referrals, billing, scheduling, and revenue cycle management. They differ from a general BPO in that they are beholden to HIPAA and must sign a Business Associate Agreement. Healthcare BPOs work inside their client’s EMR and handle patient data in their day-to-day tasks.
Also called: healthcare outsourcing, healthcare business process outsourcing, healthcare services partner
What does a healthcare BPO handle?
Healthcare BPOs are placed in charge of both the patient- and payer-facing operational work that would otherwise be staffed internally by providers, health systems, and health plans. Some of the most common services that healthcare BPOs provide include:
- Patient access and scheduling: Getting patients prompt access to care through booking, rescheduling, and confirming appointments.
- Referral intake: Processing, validating, and routing incoming referrals.
- Prior authorization: Gathering patient documents, submitting requests to payers, and following up on decisions.
- Insurance eligibility verification: Confirming that the patient has current coverage and benefits before the visit begins.
- Prescription refill calls: Handling requests and routing them appropriately.
- Enrollment: Making sign-up and onboarding a smoother process for patients and members.
- Billing and payment support: Providing support for questions about statements and patient balances.
- Revenue cycle management: Support for the financial process between the patient’s visit and their final payment.
How is a healthcare BPO different from a general BPO?
While both can handle similar tasks for clients, the differences lie in the level of regulation and sensitive information that healthcare BPOs deal with. Healthcare BPOs are beholden to HIPAA obligations, just like their clients, and must sign a Business Associate Agreement (BAA), holding them accountable for safeguarding protected health information (PHI). For that reason, security certifications built for healthcare, like HITRUST, are helpful for healthcare-related BPOs as well.
Additionally, healthcare BPOs are trained on a variety of clinical-adjacent workflows, and instead of working within a CRM, they tend to use the same EMR as their clients, such as Epic, Cerner, athenahealth, or eClinicalWorks.
How does a healthcare BPO differ from healthcare software?
Software automates the steps, while a BPO provides the people who can execute the work, including the exceptions that software doesn’t have the capacity for.
What should buyers check?
- BAA terms: Between the BPO and the healthcare provider, who is responsible for what, in terms of breach notification and subcontracting procedures?
- Security certifications and audit reports: Ask if they can provide you with the most current documentation for each, don’t just take a “badge” on their website for granted without proof.
- EMR experience: Confirm which systems they work in and if they use your current EMR.
- Accountability structure: Who is accountable for results, and who is in charge of addressing problems or reporting performance?
- Results from similar clients: What outcomes were they able to achieve for organizations that have your same size, complexity, and specialty?
FAQs
Do healthcare BPOs work in our EMR or their own systems?
Usually, they will work in your EMR. By doing this, healthcare BPOs can keep their clients’ records accurate and up to date and all in one place. A buyer should confirm with a vendor which EMRs they have experience with (including Epic, Cerner, athenahealth, eClinicalWorks, or others).
Can a healthcare BPO handle clinical work?
No. A healthcare BPO is built for operational, clinical-adjacent tasks, like intake, verification, scheduling, and authorizations. Clinical judgment should stay with licensed clinicians, in tasks like diagnosis, triage, or treatment advice.
Is a healthcare BPO the same as a medical answering service?
No. Answering services usually just take messages and relay calls, and do so after hours. A healthcare BPO runs full tasks and workflows on behalf of a provider.
