Standards in medical transcription

This all started, once again, at the AHDI Lounge. I'm just now getting to it because I got sidetracked by the whole MT Stars discussion. So follow me down this particular yellow brick road…

The topic at AHDI Lounge is AHDI and MTs. Basically, it's a highlight for the more in-depth AHDI “Let's Talk About…” series and Barb Marques' AHDI and MTs (PDF) talk-about. While Barb Marques' piece is interesting, for me the most interesting part of this AHDI Lounge post was the comments (as is usually the case).

The first comment refers to the impact the VBC (visible black character) standard (explaining why this isn't really a standard is another discussion entirely) has had on medical transcriptionist's pay rates.  To which Laura Bryan responds:

AHDI is not responsible for issuing the “VBC”. This standard was issued by MTIA and AHIMA.

Now, just to be clear: Laura Bryan has no official position with AHDI. As far as I can tell, she never has (and I'm quite certain I don't need to invite anyone to correct me if I'm wrong, but please let me know if I am). At the very least, however, she's a very vocal supporter.

To which I asked – why wasn't AHDI part of the task force on the visible black character?

And Laura responds:

@Julie, the standard was intended to address BILLING, not compensation. The MTSOs and AHIMA are most involved in billing negotiations.

When I noted that billing and compensation are related, Laura elaborates:

@Julie, I didn't say they weren't related. But it is common knowledge that billing is not necessarily calculated the same way as compensation. The standard was not intended to address methods of calculating line rates for the purpose of compensation.

The way I understand this statement, Laura believes AHDI wasn't involved in this task force because it was about billing, not compensation. This is a direct contradiction to the following statement by Barb Marques in the referenced Let's Talk About… article:

We have few weapons in the arsenal to “force” employers to alter their compensation practices. As I shared above, sometimes the only way to impact something you can’t get your hands on is to chip away at the walls around it in hopes of a breakthrough. For AHDI, that means identifying and addressing marketplace drivers that impact billing, whose inarguable bedfellow is compensation. (emphasis added)

I don't know about anyone else, but I would certainly classify the VBC white paper as a market driver that impacts billing. And let's not get confused as to the difference between recommending compensation rates and setting standards. When the organization was AAMT, it most certainly was involved in all kinds of standards setting, including billing.

One goal of the white paper was to provide a standard that would give the customer base the ability to compare apples to apples when evaluating proposals from outsourced medical transcription services. However, that was only one goal.

The goal was to implement a standard for content measurement that health information management (HIM) practitioners can use to evaluate in-house transcription staff and external transcription service suppliers.

And makes the recommendation:

The task force recommends that this definition be adopted by all organizations producing medical transcription, including those using in-house staff to transcribe dictation.

That's pretty clear intent, wouldn't you say? Anyone who thought it wouldn't impact transcriptionists working for the outsourced services is either brain dead or sleeping at the wheel.

AHIMA subsequently issued a FAQ (frequently asked questions) about the white paper, where it states that the white paper does not call for MTSOs to change compensation methods for medical transcriptionists.

Though adoption of the VBC unit for compensation of medical transcriptionists was neither the intent nor recommendation of this paper, we recognize that some will choose to adopt it for compensation and strongly encourage those service owners to engage in the same research and analysis outlined in this paper, as well as dialogue with their transcriptionists, in transitioning to this new methodology.

I read this as AHIMA backing down from what was actually published in the white paper. I question why the white paper would recommend adoption by all organizations and specifically include in-house staff if the intent wasn't to apply the VBC to calculating compensation.

Additionally, let me point out something maybe Laura has forgotten: not all medical transcriptionists – not all members of AHDI, even – work for a hospital or transcription service. I'm not quite sure how Laura could forget this, since she runs a medical transcription service and is obviously a member of AHDI. The suggestion that AHDI would decide to bow out of a task force attempting to set standards involving billing units because it didn't involve compensation suggests that AHDI isn't representing the interests of all its members.

Perhaps AHDI didn't bow out; maybe it was never invited to the table. If that was the case, it demonstrates the weak position AHDI has in the healthcare documentation community.

In all fairness, Laura does make the point that the “standard” is being applied in a detrimental way that was most likely not intended and that AHDI did say it was not in favor of the VBC without adjusting equivalent pay. This is, in fact, stated in the white paper:

Financial analysis must be completed to establish the equivalent VBC pricing in comparison with the existing rate and unit of measure. The company must then ensure the counting and financial applications are properly configured to support the new method for consistency and verifiability. As mentioned previously, comparative modeling showing each method side-by-side on invoices will more than likely be required.

The same problem came into play when the 65-character standard was enacted. But that doesn't excuse AHDI from taking a back seat in any attempt to set standards that impact the industry. The fact that there were problems associated with the 65-character line standard, which AAMT ultimately backed away from as a result of these issues, isn't a reason to bow out of any further attempts to set standards that will impact transcriptionists, the industry and compensation. I would argue, in fact, that it was an opportunity (now lost) to take the lead to make sure billing standards that could impact compensation would not be used to the detriment of transcriptionists.

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8 thoughts on “Standards in medical transcription”

  1. I followed this discussion as well. While I’m not sure and couldn’t verify it, I think those discussions were already underway before the AHDI/CDIA partnership. I do agree that AHDI should have been involved. Even if you take it as “only billing” (which I agree isn’t possible in our industry), there are many members of AHDI who are business owners. Many smaller MTSOs belong to AHDI because they either can’t afford the CDIA dues or don’t feel it’s the right place for them.

    I said at the time that the info about the VBC came out that this would really be no different than the “AAMT line.” (And no, do NOT get me started on that one!) It will be interpreted however someone chooses to interpret it and we still won’t have any standard or consistency. Not too long after it was published, I saw a proposal where it actually said that the number of billable lines would be calculated using the “VBC plus 60%.” Okay, so who decides what percentage is right? We’ll see the same variations in how someone chooses to adjust their numbers that we’ve always seen.

    And while I do agree that billing calculations and payroll calculations have often been done differently, what we do have now is an established statement from the industry that the VBC is the best way to measure MT productivity. And in our world, productivity is connected to compensation. It’s just how it is.

  2. The VBC standard clearly explains that the billable rate is to be adjusted to an “equivalent” rate so that the actual bill is not reduced. It doesn’t make sense that the business owners would publish a recommendation that would LOWER their billables by lowering the rate they charge. The standard is intended to filter out non-comparable data such as formatting codes and meta data–things that can vary from one system to another even if the printed document looks absolutely identical. It is an attempt to actually compare apples to apples when making purchasing decisions. The comment about comparing productivity between in-house and outsourced work was meant to compare the actual volume of documentation created when comparing documents created between disparate systems (as might be the case if a hospital was using in-house and outsourced labor) capable of outputting the text in formats that include/exclude header information (not headers and footers), formatting codes, and document properties. Much of this meta data has more to do with the technology in use than the work performed by the MT. Filtering the meta data and comparing raw data gives a better comparison when evaluating the pros and cons of in-house staffing vs outsourcing and is more informative when making buying decisions, etc.

    If a company chooses to use the VBC at an adjusted equivalent rate for billing and then turns around and uses the straight VBC for compensating MTs (without adjusting their per-line rate upward), they are blatantly disregarding the recommendations of the VBC. Unfortunately, unethical business practices exist in every industry. Historically, this particular industry has shown a grave disregard for business ethics. Government regulation, professional associations, industry alliances, and standards-setting organizations can only do so much. At some point, people have to choose to do the right thing and unfortunately that just doesn’t always happen (think Enron, subprime mortgages, the banking industry and Wall Street–we’ve gots lots of company).

    As to the timing of this work, Kathy is correct. MTIA formed a committee to address billing methods sometime in 2004 (well before the partnership was formed between MTIA and AHDI) and at some point began collaborating with AHIMA. The draft was sent to the AHDI BOD and AHDI staff in December of 2007 (still before the partnership was formed) for comment. AHDI BOD and staff members DID voice strong concerns at the time about the possibility of the standard being misused to downgrade MTs compensation and that we did not support the use of the VBC for compensation.

    As to why this was taken up by MTIA and AHIMA, (quoted from FAQs published in March 2007) “The collaborative efforts of these two organizations began several years ago as an effort to uniformly define a universal standard for billing for patient medical reports due to the multiple and various counting methodologies and basis for determining a transcribed line. One outcome and goal for pursuing this universal standard is that “By adopting the proposed standard unit of measure, suppliers can send a clear message that they value their credibility and are willing to have their production volume measured on the same basis as other suppliers. This will enhance the credibility of the entire industry.”

    AHDI has not ignored or failed to address compensation. AHDI has always advocated for full disclosure of compensation methods. MTs must insist that their employers/contractors provide clear, unambiguous information regarding compensation methods. See the position statement here: http://www.ahdionline.org/AdvocacyPublicPolicy/WhereWeStand/AHDIPositionStatements/AHDIStatementonFullDisclosureinTransComp/tabid/264/Default.aspx. Compensation is far more difficult to outline than simply stating a line rate. Some companies offer benies, others don’t. And yes, production almost ALWAYS has some part in the final compensation package. Only the MT can truly evaluate the entire compensation package to determine what is best for them in their particular situation and for their particular needs. The fiasco with the “AAMT line” made it pretty obvious that any attempt to “define” a “line” was meaningless and subject to wide variation in interpretation and manipulation. In actuality, the VBC paper doesn’t attempt to define a line either. The problem in the industry is not a lack of a definition or even a lack of agreement on a standard. The REAL problem is MANIPULATION. Full disclosure is intended to address the problem of manipulation.

    As to my “official position” with AHDI, I was on the BOD at the time the draft VBC was sent to AHDI for comment, and I submitted extensive and detailed comments. The following year I was on staff with AHDI. In 2009, I represented AHDI on the executive board of the Health Story Project (and am still an active volunteer with HSP) and am currently chair of the Credentialing Development Team.

  3. Just curious as to what recourse you ladies feel an MT should take with regard to companies who cheat them by paying by the VBC? I worked for Amphion last year and was hired at 8 cpl (employee/benefits) for a 65 char line. After a month, I was told they were mistaken; that I was being paid VBC @ 8 cpl (which equated to just over 6 cpl) and that for that current pay period (which was nearly at its end) I would “owe back” to the company but they would graciously (cough cough) not force me to pay back the other pay periods. I promptly resigned.

    So, from my seat, and sorry Jules if I’m totally off topic of your intent, is what recourse does an MT have when these, as noted by Laura, UNETHICAL companies directly tie their billing and their MT compensation together, when – How does an MT know at all if the billing VBC is not significantly higher than their compensating VBC is? Now I ran a service for many years, and I don’t think it’s any of the MTs business how a client is billed by an MTSO. But I do feel AHDI should be MORE OF AN ADVOCATE for MTs than for MTSOs and what I read here (and there) that simply is not the case. When pressed on the issue- it seems there’s a hands up, back-step of- Oh wait! THat’s not what we’re here for! Yet, they seemingly continue to be involved in the downward spiral that is this profession.

  4. Bambi, these are exactly the kind of examples that happen to MTs all the time. There is some recourse through the Department of Labor for pay being docked inappropriately. I’m not sure if this one fits under that.

    I agree with you that it really doesn’t matter how billing is done when it comes to MT compensation.

    Your question about what should be done. When the big announcement was made about ethical billing practices and the VBC, one of the questions I posed to my then employer, who was pretty involved with this, was who would police things. There was no response. When an industry sets standards, I believe they should be willing to step up to the plate and enforce those standards. If someone isn’t using them ethically, then, in my opinion, they shouldn’t be allowed to proudly display that “seal” they were given when they agreed to uphold the principles. Unfortunately, our industry hasn’t ever been able to figure out how to police things and require accountability.

    I think the HOPE with the CDIA/AHDI partnership was that the AHDI folks could have more influence with employers. That hasn’t happened. And in the end, as was said by many at the time, no one can serve two masters. It’s near impossible to speak out about things that are being done by your dues paying members and still maintain an organization.

    Standards like this are ambiguous at best and ripe for manipulation. It’s no different than previous attempts to define the line. And sadly, they will indeed be manipulated.

  5. I just realized that I was one year off on my dates. I was on staff in 2007 (not the BOD) when the draft was given to AHDI for review. I reviewed the document and submitted my comments as a staff member, not as a member of the board. Not sure it makes a lot of difference, but I do want to be truthful 🙂

  6. Bambi, you wrote: “But I do feel AHDI should be MORE OF AN ADVOCATE for MTs than for MTSOs and what I read here (and there) that simply is not the case.”

    In what ways specifically is AHDI more of an advocate for MTSOs than for MTs?

  7. @Laura: It really doesn’t matter whether the intent of the document was billing – it was a white paper to set a standard for the industry and in my opinion, AAMT/AHDI should have been in a leadership role in setting that standard. There’s a lot of talk about leadership at AHDI, but action – not so much. Much of what happens is reactive, not proactive.

    As a member who is also an MTSO, don’t YOU feel your interests should have been represented in that discussion?

    But water under the bridge and all…

    AHDI then failed to take leadership in educating its members about compensation and it continues to fail in that regard. In my experience with AAMT, the level of sensitivity over any discussion regarding compensation was so acute, it stopped ANY discussion that involved compensation. I think it would be beneficial to all members – employees, independent contractors, MTSOs – to have in-depth education about standards, billing practices and compensation schemes.

    Having been an MTSO herself, Bambi is better equipped than most MTs, but I don’t consider her average.

  8. “but I don’t consider her average.”

    Awwwwwwwwwww, and my heart grew two sizes that day 🙂

    (Sorry no time for substantive discourse, I’ve got chairs to spray paint!)

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