3

Thursday, April 10, 2014

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 3

See the First and second part for better understanding.

Qualifying Individual (QI)

A QI is an individual who:
 ■ is entitled to Part A;
 ■ has income that is at least 120 percent of the
 ■ FPL, but less than 135 percent of the FPL;
 ■ has resources that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

A QI is similar to an SLMB in that the only benefit available is Medicaid payment of the Medicare Part B premium; however, expenditures for any QI are 100 percent federally funded and the total expenditures are limited by statute.


Full Benefit Dual Eligible (FBDE)

An FBDE is an individual who:

 ■ is eligible for Medicaid either categorically or through optional coverage groups, such as Medically Needy or special income levels for institutionalized or home
and community-based waivers; and
 ■ does not meet the income or resource criteria for a QMB or an SLMB.


Qualified  Disabled and Working Individual (QDWI)

A QDWI is an individual who:

 ■ lost Medicare Part A benefits due to returning to work, but is eligible to enroll in and purchase Medicare Part A;
 ■ does not have an income that exceeds 200 percent of the FPL;
 ■ has resource that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation; and
 ■ may not be otherwise eligible for Medicaid.

A QDWI is only eligible for Medicaid payment of Part A premiums.


Balance Billing a QMB

For a QMB, Medicaid is responsible for deductible, coinsurance, and copayment amounts for Medicare Part A and Part B covered services. Providers may not bill a QMB for either the balance of the Medicare rate or the provider’s customary charges for Part A or Part B services. The QMB is protected from liability for Part A and Part B charges, even when the amounts the provider receives from Medicare and Medicaid are less than the Medicare rate or less than the provider’s customary charges, as specified in the Balanced Budget Act of 1997 (BBA). Providers who bill a QMB for amounts above the Medicare and Medicaid payments (even when Medicaid pays nothing) are subject to sanctions. Providers may not accept QMB patients as “private pay” in order to bill the patient directly, and providers must accept Medicare assignment for all Medicaid patients, including QMBs.


Friday, April 4, 2014

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 2


Dual Eligible Medicare Beneficiary Groups

See the First part for better understanding.

Qualified Medicare  Beneficiary (QMB Only)

A QMB is an individual who:
 ■ is entitled to Medicare Part A;
 ■ has income that does not exceed 100 percent of the Federal Poverty Level (FPL); and
 ■ has resource that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

A QMB is eligible for Medicaid payment of Medicare premium, deductible, coinsurance, and copayment amounts (except for Part D). A QMB who does not qualify
for any additional Medicaid benefits is called a “QMB Only.”

QMB Plus

A QMB Plus is an individual who:
 ■ meets all of the standards for QMB eligibility as described above;
 ■ meets the financial criteria for full Medicaid coverage; and
 ■ is entitled to all benefits available to a QMB, as well as all benefits available under the State Medicaid plan to a fully eligible Medicaid recipient.

These individuals often qualify for full Medicaid benefits by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy level.

Specified  Low-Income  Medicare  Beneficiary (SLMB Only)

An SLMB is an individual who:
 ■ is entitled to Medicare Part A;
 ■ has income that exceeds 100 percent of the FPL, but less than 120 percent of the FPL; and
 ■ has resource that do not exceed three times the Supplemental Security Income (SSI) limit, adjusted annually for inflation.

The only Medicaid benefit for which an SLMB is eligible is payment of Medicare Part B premiums. An SLMB who does not qualify for any additional Medicaid benefits is
called an “SLMB Only.”

SLMB Plus
An SLMB Plus is an individual who:
 ■ meets the standards for SLMB eligibility;
 ■ meets the financial criteria for full Medicaid coverage; and
 ■ is entitled to payment of Medicare Part B premiums, as well as all benefits available under the State Medicaid plan to a fully eligibleMedicaid recipient.

These individuals often qualify for full Medicaid benefits by meeting the Medically Needy standards, or through spending down excess income to the Medically Needy
level.

Continued in next part

Thursday, March 27, 2014

Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) at a Glance - Part 1


The Original Medicare Program, Title XVIII of the Social Security Act (SSA), provides hospital insurance, known as Part A coverage, and supplementary medical insurance, known as Part B coverage. Coverage for Part A is automatic for individuals age 65 or older (and for certain disabled individuals) who have insured status under Social Security or Railroad Retirement. Most individuals do not pay a monthly premium (amount paid to Medicare, an insurance company, or a health care plan for health coverage) for Part A if they or their spouse paid Medicare taxes while working. Coverage for Part A may be purchased by individuals who do not have insured status through the payment of monthly Part A premiums. Coverage for Part B does require payment of monthly premiums.


Individuals with Original Medicare generally pay:
 ■ a deductible (a fixed amount per year for health care before Medicare pays its share);
 ■ coinsurance (a percentage of the cost of the covered services and/or supplies); and
 ■ may pay a copayment (fixed dollar amounts that an individual must pay when he or she uses a particular service).

Individuals with Original Medicare who desire Medicare drug coverage must join a Medicare Prescription Drug Plan.Medicare Advantage (MA) plans are also part of Medicare. These health plan options, known as Part C plans, are offered by private companies and approved by Medicare. MA plans are not supplemental insurance. These plans must provide all Part A and Part B coverage and follow rules set by Medicare, including benefit design and cost-sharing.

Medicare Cost-Sharing for Medicaid Recipients


Medicaid is a joint Federal and State program that helps pay medical costs for individuals with limited income and resources. Individuals with Medicare Part A and/or Part B, who have limited income and resources, may get help paying for their out-of-pocket medical expenses from their State Medicaid Program. These programs help individuals with Medicare save money each year. Medicare cost-sharing includes Part A and Part B premiums and, in some cases, may also include Part A and Part B deductible, coinsurance, and/or copayment.

The SSA provides that a State Medicaid plan is not required to provide payment for any expenses incurred for a deductible, coinsurance, or copayment for Medicare
cost-sharing to the extent that the Medicare payment for the service would exceed the payment amount that would be made under the State Medicaid plan. In any case
where a Medicare deductible, coinsurance, or copayment is required to be paid or may be paid conditionally, the State may limit Medicaid payment, including nominal
cost-sharing amounts as permitted under the SSA and specified in the State Medicaid plan. These payment limitations may result in a Medicaid payment of zero.

For individuals with an MA plan, cost-sharing includes premiums plus a deductible and coinsurance, and may include copayment. Additional factors also determine
whether Medicaid is liable for coverage of cost-sharing in MA plans. These factors include the dual eligible coverage category, the type of cost-sharing, the options elected by the State, and payment limitations specified in the State Medicaid plan.

Individuals who are entitled to Medicare Part A and/or Part B and are eligible for some form of Medicaid benefit are often referred to as “dual eligibles.” These
benefits are sometimes referred to as Medicare Savings Programs (MSPs). Dual eligibles are eligible for some form of Medicaid benefit, whether that Medicaid coverage
is limited to certain costs, such as Medicare premiums, or the full benefits covered under the State Medicaid plan.

Dual eligibles whose benefits are limited include:
 ■ Qualified Medicare Beneficiaries (QMB);
 ■ Specified Low-Income Medicare Beneficiaries (SLMB);
 ■ Qualifying Individuals (QI); and
 ■ Qualified Disabled Working Individuals (QDWI).

Those eligible for full Medicaid benefits are called Full Benefit Dual Eligibles (FBDE). At times, individuals may qualify for both limited coverage of Medicare cost-sharing as well as full Medicaid benefits.

Would be continued in next part

Friday, March 21, 2014

Medicare ABN - If patient has other insurance - what is the procedure

Effect of Other Insurers/Payers  

If a beneficiary is eligible for both Original Medicare and Medicaid (dually eligible) or is covered by Original Medicare and another insurance program or payer (such as waiver programs, Office on Aging funds, community agencies (e.g., Easter Seals) or grants), ABN requirements still apply.   For example, when a beneficiary is a dual eligible and receives home health services that are covered only under Medicaid, but are not covered by Medicare for one of the reasons listed in Table 1; an ABN
must be issued at the initiation of this care to inform the beneficiary that Medicare will likely deny the services.  

Some States have specific rules regarding HHA completion of liability notices in situations where dual eligible beneficiaries need to accept liability for Medicare noncovered care that Medicaid will cover.  Medicaid has the authority to make this assertion under Title XIX of the Act, where Medicaid is recognized as the “payer of last resort” (meaning other Federal programs like Medicare (Title XVIII) must pay in accordance with their own policies before Medicaid assumes any remaining charges)

On the ABN, the first check box under the “Options” section indicates the choice to bill Medicare and is equivalent to the third checkbox on the outgoing HHABN. HHAs serving dual eligibles should comply with existing HHABN State policy within their jurisdiction as applicable to the ABN unless the State instructs otherwise.

Note: If a State has issued a directive to select the third checkbox on the HHABN, HHAs must mark the first check box when issuing the ABN.

Where there is no State specific directive, HHAs are permitted to instruct beneficiaries to select Option 1 on the ABN when a Medicare claim denial is necessary to facilitate payment by Medicaid or a secondary insurer. HHAs may add a statement in the “Additional Information” section to help a dual eligible better understand the payment situation such as, “We will submit a claim for this care to your

other insurance,” or “Your Medical Assistance plan will pay for this care.” HHAs may also use the “Additional Information” on the ABN to include agency specific information on secondary insurance claims or a blank line for the beneficiary to insert secondary insurance information. Agencies can pre-print language in the “Additional Information” section of the notice.

Thursday, March 13, 2014

What are cases can HHA give ABN TO beneficiary - time period of ABN

HHA Triggering Events

HHAs may be required to provide an ABN to an Original Medicare beneficiary when a triggering event occurs. Table 2, below, outlines triggering events specific to HHAs.

 Event Description 

Initiation    When an HHA expects that Medicare will not cover an item and/or service delivered under a planned course of treatment from the start of a spell of illness, OR before the delivery of a one-time item and/or service that Medicare is not expected to cover.

Reduction When an HHA expects that Medicare coverage of an item or service will be reduced or stopped during a spell of illness while continuing others, including when one home health discipline ends but others continue.

Termination When an HHA expects that Medicare coverage will end for all items and services in total.

•  HHA Initiations  

The HHA must issue a beneficiary an ABN prior to delivering care that is usually covered by Medicare,
but in this particular instance, the item or service may not be or is not covered by Medicare because:
−  The care is not medically reasonable and necessary;
−  The beneficiary is not confined to his/her home (is not considered homebound);
−  The beneficiary does not need skilled nursing care on an intermittent basis; or
−  The beneficiary is receiving custodial care only.
 Note: If the HHA believes that Medicare will not (or may not) pay for care for a reason other than
ones listed directly above, issuance of the ABN is not required.
 
INITIATION EXAMPLE: A beneficiary requires skilled nursing wound care 3 times weekly; however, she is not confined to the home. She wants the care done at her home by the HHA.  The HHA must issue the ABN to this beneficiary before providing the home care that will not be paid for by Medicare. This allows the beneficiary to make an informed decision on whether to receive the non-covered care, and to accept the financial obligation.

An ABN, signed at initiation of home health care for items and/or services not covered by Medicare, is effective for up to a year; as long as the items/services being given remain unchanged from those listed on the notice.

•  HHA Reductions  
Reductions involve any decrease in services or supplies, such as frequency, amount, or level of care that an HHA provides and/or that is part of the Plan of Care (POC). If a reduction occurs for an item or service that will no longer be covered by Medicare, but the beneficiary wants to continue to receive the item or service and will assume the financial charges, the HHA must issue the ABN prior to providing the noncovered items or services. (Technically, this is an initiation of noncovered services following a reduction of services).  

REDUCTION WITH SUBSEQUENT INITIATION EXAMPLE: A beneficiary requires Physical Therapy (PT) for gait retraining 5 times per week for 2 weeks, then reduce to 3 times weekly for 2 weeks.  After 2 weeks of PT, the beneficiary wants to continue therapy 5 times a week even though this amount of therapy is no longer medically reasonable and necessary. The HHA would issue an ABN so that he understands the situation and can consent to financial responsibility for the PT not covered by
Medicare.

•  HHA Terminations  
A termination is the cessation of all HHA-provided Medicare covered services. If a beneficiary wants to continue receiving home health care that will not be covered by Medicare for any of the statutory reasons listed in Table 1 and a physician orders the services; the HHA must issue the beneficiary an ABN in order to charge the beneficiary or a secondary insurer. If the beneficiary will not be getting any further home care after discharge, there is no need for ABN issuance.

When all Medicare covered home health care is terminated, HHAs may sometimes be required to deliver the Notice of Medicare Provider Non-Coverage, (NOMNC), CMS-10123. The NOMNC informs beneficiaries of the right to an expedited determination by a Quality Improvement Organization (QIO) if they feel that termination of home health services is not appropriate. Detailed information and instructions for issuing the NOMNC can be found on the CMS website under the link for “FFS ED Notices” at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on the CMS website.  

If a beneficiary requests a QIO review upon receiving a NOMNC, the QIO will make a fast decision on whether covered services should end. If the QIO decides that Medicare covered care should end and the beneficiary wishes to continue receiving care from the HHA even though Medicare will not pay, an ABN must be issued since this would be an initiation of non-covered care.

Friday, March 7, 2014

ABN notice for - Home health agency

Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 

This article is based on Change Request (CR) 8404 which provides: 1) instructions for Home Health Agency (HHA) use of the Advance Beneficiary Notice of Noncoverage (ABN) to replace the outgoing Home Health Advance Beneficiary Notice (HHABN), Form CMS-R-296, Option Box 1; 2) ABN issuance guidelines for therapy services and therapy specific examples; and 3) minor editorial changes  to clarify existing manual instructions regarding ABN issuance.

Home health agencies and therapy providers should make sure that their health care and billing staff are aware of these ABN policy changes. All other providers should note that there have been no substantive changes to the ABN form or general instructions for issuance and can reference MM7821 (available at http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/mm7821.pdf) for general ABN information.


HHA Use of ABN – General Use


HHAs are required to issue an ABN to Original Medicare beneficiaries in specific situations where “Limitation on Liability” (LOL) protection is afforded under Section 1879 of the Act for items and/or services that the HHA believes Medicare will not cover (see Table 1 below). In these circumstances, if the beneficiary chooses to receive the items/services in question and Medicare does not cover the home care, HHAs may use the ABN to shift liability for the non-covered home care to the beneficiary.

ABNs are not used in managed care; however, when a beneficiary transitions to Medicare managed care from Original Medicare during a home health episode, ABN issuance is required when there are potential charges to the beneficiary that fall under the LOL projections. HHAs should contact their RHHI if they have questions on the ABN or related instructions, since RHHIs process home health claims for Original Medicare. The following chart summarizes the statutory provisions related to ABN issuance for LOL purposes.

The below situation ABN can we givein - Brief Description of Situation

Care is not reasonable and necessary
Custodial care is the only care delivered
Beneficiary does not need skilled nursing care on an intermittent basis

If one of the above situations applies and the beneficiary chooses to receive the  home care items/services that may not be covered by Medicare, HHAs must issue the ABN to the beneficiary to notify him/her of potential financial responsibility. In addition, when Medicare considers an item or service experimental (e.g., a “Research Use Only” or “Investigational Use Only” laboratory test), payment for the experimental item or service is denied under Section 1862(a)(1) of the Act as not
reasonable and necessary. In circumstances such as this, the beneficiary must be given an ABN.

Thursday, February 27, 2014

Rejection due to NPI cross walk, Data element missing

Crosswalk did not give 1 to 1 match for NPI 

What this means: The payer does not recognize the provider matched to the NPI tax ID combination in thier system.

Provider action: Check your NPI and tax ID numbers, are you sending the claim how you are credentialled with the payer, verify this provider is credentialled under the Billing NPI or individual provider NPI.  You may need to contact the payer to retrieve this information?

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.



A data element with 'Must Use' status is missing. Element CR104 

What this means: Some claims submitted October 29, 2012 through November 6, 2012 erroneously rejected with the message, “A data element with 'Must Use' status is missing. Element CR104 (Ambulance Transport Reason Code) is m".

Provider action: No provider action is required.

Rejection Removal: Rejections will  be removed by   EDI as they are invalid.

Re-filing:   EDI will re-process the affected claims.


ACKNOWLEDGEMENT RETURNED AS UNPROCESSABLE CLAIM

What this means: Our trading partner invalidly rejected claims between the dates of 02/24/2012-06/04/2012.

Provider action: Check your tricare claims and verify if they rejected for this reason.

Rejection Removal: Rejections will not be removed by   EDI.

Re-filing: You would want to re-file any claims between these dates that rejected for this reason.








Friday, February 21, 2014

EDI - rejection - provider specialty code, Expired tax id

 000 ERROR: Provider's specialty code

What this means: The rendering provider information is either incomplete or missing from the   EDI system, or it doesn't match what is being sent on the claim.  

Provider action: Check the rendering provider.  Is it present on the claim?  Is it a provider you have already added to   EDI?  

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any



*Expired Tax ID  Dr. XXXXXX

What this means: The tax ID and provider information that the payer has on file is not longer set up in the payer system.

Provider action: Please contact provider relations at insurance to make sure your provider information is active in their system,


Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


*Wrong Name .


What this means: The provider name being sent on the claim is coming over in first name last name format, ASHN wants it in last name, first name format.

Provider action: Check the rendering provider.  Is it present on the claim?  How are you sending the name?

Rejection Removal: Rejections will not be removed by   EDI as they are valid.

Re-filing: Once this is corrected, you would want to re-file any claims that rejected for this reason.


Null” or no rejection message

What this means: Claims submitted on 2/5/2013 may have rejected for "NULL" or with no error message.

Provider action: Check and see if you received any of these rejections for this payer in this time frame.

Rejection Removal: Rejections will be removed by   EDI.

Re-filing: The payer will be reprocessing these claims.






Wednesday, February 12, 2014

How to avoid or preventing duplicate denial OA 18

Exact duplicate claim/service

(DUPLICATE CHARGE PAID ?002XX ON CLAIM ?001XXXXXXXXX)

(DUPLICATE CHARGE OF CLAIM ?001XXXXXXXXX NOW BEING PROCESSED)

(THIS IS A DUPLICATE OF A CHARGE WE HAVE PROCESSED)

(MORE THAN 1 E/M SERVICE BILLED ON THE SAME DAY)

Resources/tips for avoiding this denial

Before resubmitting a claim, check claims status via the SPOT (Secure Provider Online Tool) or the Part B interactive voice response (IVR) system.

• Do not resubmit an entire claim when partial payment made; when appropriate, resubmit denied lines only.

• Click here to review article on new claim system edits regarding duplicate claims.

• Ensure necessary appropriate modifiers are appended to claim lines.

• Refer to the Modifier FAQs here on the First Coast Medicare provider website for additional information.

Preventing duplicate claim denials 

Effective July 1, 2013, new claim system edits may result in additional duplicate claim denials to your practice. Please share this information with your billing companies, vendors and clearing houses. The Centers for Medicare & Medicaid Services (CMS) has instructed Medicare contractors to enhance claim system edits to include same claim details in its history review of duplicate procedures and/or services. The edits will search within paid, finalized, pending and same claim details in history. This means that unless applicable modifiers are included in your claim, the edits will detect duplicate and repeat services within the same claim and/or based on a claim previously submitted.

To minimize a potential increase in duplicate claim denials, please review your billing software and procedures to ensure that you are billing correctly. Some services on a claim may appear to be duplicates when, in fact, they are not. Please ensure appropriate use of modifiers to identify procedures and services that are not duplicates. A complete list of modifiers can be found in the Current Procedural Terminology (CPT®) codebook. The following are a few examples of modifiers that may be used, as applicable, to identify repeat or distinct procedures and services on a claim:

• Modifier 76 may be used to indicate a repeat procedure or service by the same provider, subsequent to the original procedure or service.

• Modifier 91 may be used to indicate repeat clinical diagnostic laboratory tests.  This modifier is added only when additional test results are medically necessary on the same day.

• Modifier 59 may be used, as applicable, to identify procedures or services that are normally reported together but are appropriate to be billed separately under certain circumstances. Modifier 59 indicates a procedure or service by the same provider, distinct or independent from other services, performed on the same day.

Monday, February 3, 2014

Dont call Medicare toll free service line for claim status

Customer service representatives cannot provide claim status via the toll-free service line


Medicare guidelines, specifically, the Internet-only manual (IOM) Publication, 100-09 Chapter 6 Section 50.1 requires that providers call the interactive voice response system (IVR) to obtain claim status.  Service associates responding to calls via our toll-free service line are not allowed to provide claim status.  To do so
would be in violation of Medicare service guidelines.

First Coast Service Options’ (First Coast’s) customer service representatives (CSRs) continue to receive a large volume of calls from providers asking for claim status.  In the majority of cases the calls are coming from entities representing Medicare providers.  Because many providers have chosen to outsource their claims monitoring activities, they may not be aware that the entities representing them are calling the toll-free CSR service line for status of claims instead of using the IVR.

When claim status calls are made to the toll-free CSR service line, it slows our response time for other calls coming into our call center because service associates are attempting to explain to customers that status cannot be released via the general inquiry service line.  It is the responsibility of Medicare providers to notify the entities representing them that claim status inquiries must be made via the IVR or our new Internet portal the SPOT. See http://medicare.fcso.com/Landing/256747.asp.

Medical Billing

What is the overall Billing process?

The physician doesn’t get paid for his services immediately after they are rendered. Majority of the patients have insurance coverage and details of such coverage are provided to the physician before treatment. It is the responsibility of the physician to submit claims to the insurance company and get paid for his services. Submitting Claims and getting paid is a lengthy process and involves a lot of rules and regulatory systems and is very complicated. The physician needs to adhere to all these rules before submitting claims. This is the concept of Medical Billing. Sometimes the physician cannot provide his entire attention to this activity. He entrusts this activity to Billing Companies. This is a process of the physician providing rights to Billing Companies to bill Medical Insurance claims in order to save his time energy, and money.

After the provider renders services to the patient, the billing company will submit bills to the insurance company/ payer, using the insurance information that was last provided, as well as information about the reason for the examination, and the exact type of procedure performed.

Medical coding is the process of converting Medical terms to numeric code and it required Medical knowledge skills.

Medical billing is the process of submitting the claims and get paid behalf of provider.

I have listed the important process in Medical Billing. Each process is very important.


1. Insurance verification.

2. Demo and Charge entry process.

3. Claim submission.

4. Payment posting.

5. Action on denials or Denial management or Account receivables.


Insurance verification

Process started from here and usually front desk people are doing this process. Its a process of verifying the patients insurance details by calling insurance or through online verification. If this department works well, we could resolve more problem. We have to do this even before patient appointment.

Demo and Charge entry process

Demographic entry is nothing but capturing all the information of patients. It should be error free.

Charge-entry is one of the key departments in Medical Billing. Key department?? Yes, that's true. It is the keying-in department in Medical Billing. After receiving the super bills from the Doctor's office, it gets passed through the coding department, and then comes to the charge-entry department.


A Charge-entry person also has one other vital role to perform. That is, to look-up the codes entered in the claim, and to assign the relevant charges for those codes.

Claim submission Process

The next step after demographics and charge entry is claim generation. Claims may be paper claims or electronic claims. There are various types of forms for paper claims. The most widely used form is Health Care Finance Admin-1500 designed by the Health Care Financing Administration.

Electronic transmission of claims is the modern way of sending claims with less paper work. The most common means of transmission are through internet . The claim information is directly loaded into the insurance company's computer system or to the clearing house.


Payment Posting Process

Once the claims reach the carriers and they complete processing, they issue a check and prepare an Explanation of Benefits . The checks and the Explanation of Benefits would be sent to the pay-to address with the carrier or in the Health Care Finance Administrators.


In this processing we have accounted the money into the account as per the Explanation of Benefits. Now a days we are using Electronic payment posting also.

Action on denials or Denial management or Account Receivables

This is a most important function in the process flow of data. Unless this is taken care of, insurance balance will only be on an upward trend.

Problem in Medical Billing

•Inaccurate or lack of coding

• Incomplete claims

• Lack of supporting documentation

• Poor communication with the payer

• Not billing for services rendered

* Not being follow up AR balance claims


The person who is doing this process will be called Medical billing specialist.

Who is Medical Billing Specialist.

Medical billing Specialist is the one who is handling the below process and having well knowledge in each and every process.

* Insurance verification process

* Patient demographic and charge entry process.

* Submitting the claims by electronic as well as paper method. Tracking various claim submission report.

* Payments posting process for insurance as well as patient.

* Denial management.

* Insurance followup management.

* Insurance appeal process.

* Handling patient billing inquiries.

* Patient statement process.

* Preparing monthly reports such as revenue report and account receivable report and as per the provider requirement.

Medical Billing Specialists are in charge of reviewing patient charts and documents. They prepare and review all medical insurance claims based on the rules and regulations of insurance companies. Medical Billing Specialists also review insurance communications, payment and rejection notices to properly track all claims and payments.


Medical Billing specialist Professional

If a person is computer literate he is a fit enough candidate to take up the profession of medical billing and medical coding. However he will need to be trained and be aware of a lot of new information before he can start working effectively. He has to learn about the medical billing software and must be familiar with and master the various commands used while working with it.


Who are medical coders and how is it related to medical billing? Medical billing is a sub specialty of medical coding. Medical coding is the first step in the billing process. All patient records are maintained using the ICD-9 index system so that it is compliant with the federal rules.

A medical Biller’s most important skill includes filling up of the various medical forms correctly without any mistakes what so ever. All information required should be complete without any mistake at all. And the work will be include the following

Patient demographic entry

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

Scheduling and rescheduling

Account receivable follow-ups and collections

Is it worth taking a medical billing program?

Usually don't spend too much cost on Medical billing program because the program will not do anything with real experience. What you learn from these kind of program will not be going to match with when you are working in the real environment. Hence just use as the start kind of program and get the real time experience even in small salary and later you can come up with more demanding one.


Problem of In House Processing of Medical Claims

Medical claims are generally very complex and have long extended details. While processing medical claims, one has to be highly critical and do efficient follow-up in order to get results. The process requires a lot of time and effort. And even after all this, there can be cases where files get lost or a small error can ruin the entire lot and everything has to be re-submitted again. Usually practice staff can be held up with lot of current work rather than submitting the claim and resubmitting the corrected claim hence it will lead to time delay on payment flow and it will affect all the relationship with in the practice. Even cost wise is also not effective when compare to outsourcing.

Advantage of Medical Billing Outsource

Medical Billing Company helps you in managing all your billing requirements proficiently. By choosing right medical billing company, you can get benefit such as improved financial strength.

Medical Billing task is very tedious and time consuming. However, billing must require more accuracy and special attention to strengthen the financial condition of clinical or hospital. You can do this task at own or assign to clinical staff but you have to be pleased with low patients satisfaction. Medical billing company can help you in supportive task. By efficient medical service, you will get highly satisfied patients.

A Medical Billing service can improve the efficiency of your billing system, reduce denials, cut down operating costs, boost reimbursements and save valuable time that can be devoted to patient care. These services are better equipped to adapt to continuously changing billing codes and industry requirements.


* Prince is low compare to doing it in house

* Dedicated Highly Skilled Professionals

* No need to maintain the hardware . Ability to perform Medical Billing remotely, using the software of your choice

* Usually Maximum reimbursements and fewer denials

* Accuracy is high when compare

* Faster transaction


Question need to ask when Medical Billing Outsourcing

1. Check with their referral and how long they are doing this business.

2. Are they HIPAA compliance

3. Where they are doing their work. If possible just visit there.

4. Data security.

5. Compare the price with others.

6. what are the reports they will provide

7. Your specialty wise question

8. Their software skills.


Services and process involved in Medical Billing

* Coding ( CPT, ICD-9, and HCPCS)

* Patient Demographics Entry

* Charge Entry – All specialties

* Payment Posting (Manual and Electronic)

* Payment Reconciliation

* Denials/rejections analysis, re-billing

* Accounts Receivable Follow-up

* Systemic A/R projects, re-billing

* Collection Agency Reporting

* Refunds


Medical Billing Salary Range

Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.


Most of the medical Billers are paid hourly, rather than annually. While Biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These spammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

Selecting Medical Billing Software - 10 things to consider

1. The first step is to evaluate your needs. And when evaluating different systems look for a package that goes one step ahead of billing. Choose a medical practice management system MPP. This will handle considerably more that just medical billing.

2. Determine whether the system handles electronic transmission of claims, direct billing for patients, co-pays, co-insurance, and expenses not covered by insurance.

3. Weigh the pros and cons of different medical billing systems and ask to see a system in operations. Always check out the references yourself.

4. Look for a medical billing management system that is user friendly. When a vendor demonstrates get your office staff to be present. This way you will be able to check how the software functions. Any software must be easy to use to be productive. The system should be fool proof.

5. Ask whether the medical billing software is a traditional system, one that will work on your office computers or an application service provider system (ASP), one that will process data at the software company’s data center.

6. Always get quotes from at least three medical billing software providers.

7. Ask whether they are offering an evaluation period or trial. This will enable you to know in actuality whether the system works or not.

8. Find out about training your office people, up-gradation of system, and whether the software is compatible with your office computer systems

.9. Find out whether the system will handle appointment scheduling, maintenance of records and so on apart from electronic medical records, SOAP notes, and billing. Choose a system that is comprehensive.

10. An ideal Medical Billing software system must include aspects like payment posting, reconciliation; follow up, secondary submission, and patient billing.Choose a transparent billing system that enhances your office efficiency. Install a system that you can use not one that will lead to frustration and problems.Medical billing systems must free your time and that of your office staff not make you run in circles. Choose a system with care.



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