3

Tuesday, October 28, 2014

Medicare Payment Floor Standards detailed review`


The “payment floor” establishes a waiting period during which time the contractor may not pay, issue, mail, or otherwise finalize the initial determination on a clean claim. The “payment floor date” is the earliest day after receipt of the clean claim that payment may be made.

The payment floor date is determined by counting the number of days since the day the claim was received, i.e., the count begins the day after the day of receipt.

There are different waiting periods, and thus different payment floor dates, for electronic claims and paper claims. The waiting periods are 13 days for electronic claims and 26 days for paper claims. For the purpose of implementing the payment floor, the following definitions apply:

An “electronic claim” is a claim submitted via central processing unit (CPU) to CPU transmission, tape, direct data entry, direct wire, or personal computer upload or download. A claim that is submitted via digital FAX/OCR, diskette, or touch-tone telephone is not considered as an electronic claim.

A “paper claim” is submitted and received on paper, including fax print-outs. This also includes a claim that the contractor receives on paper and then reads electronically with OCR technology

Also, for the purpose of implementing the payment floor, effective 7/1/04 and for the duration of the HIPAA contingency plan implementation, an electronic claim that does not conform to the requirements of the standard implementation guides adopted for national use under HIPAA, including electronic claims submitted electronically using pre-HIPAA formats supported by Medicare, is considered to be a paper claim.

Based on the waiting periods, the payment floor dates are as follows:

Claim Receipt Date                     Payment Floor Date

10-01-93 through 6/30/04       14th day for EMC 27th day for paper claims
07-01-04 and later                  14th day for HIPAA-compliant EMC
                27th day for paper and non-HIPAA EMC
01/01/2006 and later 29th day for paper

Except as noted below, the payment floor applies to all claims. The payment floor does not apply to: “no-payment claims, RAPs submitted by Home Health Agencies, and claims for PIP payments.

NOTE: The basis for treating a non-HIPAA-compliant electronic claim as a paper claim for the purpose of determining the applicable payment floor is as follows: Effective October 16, 2003, HIPAA requires that claims submitted to Medicare electronically comply with standard claim implementation guides adopted for national use under HIPAA. A claim submitted via direct data entry (DDE), if DDE is supported by the contractor is considered to be a HIPAA-compliant electronic claim. A contingency plan has been approved to enable claims to continue to be submitted temporarily after October 15, 2003 in a pre-HIPAA electronic format supported by Medicare. Effective July 1, 2004, the Medicare contingency plan is being modified to encourage migration to HIPAA formats. Effective July 1, 2004, for purposes of the payment floor, only those claims submitted in a HIPAA-compliant format will be paid as early as the 14th day after the date of receipt. Claims submitted on paper after July 1, 2004 will not be eligible for payment earlier than the 27th day after the date of receipt. All claims subject to the 27-day payment floor, including non-HIPAA electronically submitted claims, are to be reported in the paper claims category for workload reporting purposes. Effective January 1, 2006, paper claims will not be eligible for payment earlier than the 29th day after the date of receipt.

This differentiation in treatment of HIPAA-compliant and non-HIPAA-compliant electronic claims does not apply to Contractor Performance Evaluation (CPE) reviews of carriers and FIs conducted by CMS. For CPE purposes, carriers and FIs must continue to process the CPE specified percentage of clean paper and clean electronic (HIPAA or non-HIPAA) claims within the statutorily specified timeframes. Effective for claims received January 1, 2006 and later, clean paper claims will no longer be included in CPE scoring for claims processing timeliness.

Thursday, October 16, 2014

What is Other Claims (other than clean) and Data Element matrix


Claims that do not meet the definition of “clean” claims are “other” claims. “Other” claims require investigation or development external to the carrier or FI’s Medicare operation on a prepayment basis. “Other” claims are those that are not approved by CWF for payment that the FI identifies as requiring outside development. Examples are claims on which the provider’s FI/carrier:

• Requests additional information from the provider or another external source. This includes routine data omitted from the bill, medical information, or information to resolve discrepancies;

• Requests information or assistance from another contractor. This includes requests for charge data from the carrier, or any other request for information from the carrier;

• Develops Medicare Secondary Payer (MSP) information;

• Requests information necessary for a coverage determination;

• Performs sequential processing when an earlier claim is in development; and

• Performs outside development as a result of a CWF edit.

Data Element Requirements Matrix

The matrix (See Exhibit 1) specifies data elements, which are required, not required, and conditional for FI claims. The matrix does not specify item or field/record content and size. Refer the electronic billing instructions (UB-04 and ANSI 837) on the CMS Web site to build these additional edits. If a claim fails any one of these “content” or “size” edits, the FI returns the unprocessable claim to the supplier or provider of service.

The FIs must provide a copy of the matrix listing the data element requirements, and attach a brief explanation to providers of service and suppliers. The matrix is not a comprehensive description of requirement that need to be met in order to submit a compliant transaction.

Friday, October 3, 2014

How Medicare Determining and Paying Interest

The contractor must pay interest on clean, non-PIP (FIs) claims for which it does not make payment within the payment ceiling specified in § 80.2.1.1, provided payment is due on such claim. The interest rate and formula for calculation are shown above. The interest rate is determined by the rate applicable on the carrier or FI’s payment date.

The contractor applies interest to the net payment amount after all applicable deductions are determined (e.g., deductible, copayment, and/or MSP). Interest is rounded to the nearest penny.

A. Reporting Interest Payment on Remittance Record
See 100-22 for remittance advice completion instructions

B. Payment Made to Beneficiary
If interest is paid on a claim for which payment is made directly to the beneficiary, the contractor adds the following messages on the beneficiary notice:
“Your payment includes interest since we were unable to process your claim timely.”

C. Claims Paid Upon Appeal
Interest payments are not payable on clean claims initially processed to denial and on which payment is made subsequent to the initial decision as a result of an appeal request. This applies to appeals where more than the applicable number of days elapsed before an initial denial, but the claim was later paid upon appeal. Where an appeal of a previously paid claim results in increased payment FIs follow the following section.

D. Interest on Postpayment Denials and Other Adjustments
If a paid claim is later denied in full, the carrier or FI recovers any interest paid as well as the incorrect payment. It does not pay interest on the related no payment bill. If the claim is partially denied, interest is payable on the reduced amount. The FI recalculates the interest due based upon the new reimbursement amount. It uses the rate of interest and elapsed days applicable to the original claim. This can be accomplished by applying a ratio of the new reimbursement amount (from its debit action) to the reimbursement amount on the initial claim (from its credit action). It multiplies the result by the interest amount paid on the initial claim. The result is the interest amount payable on its debit action. The following formula is used to calculate interest:

Interest = Debit action reimbursement amount
           Credit action reimbursement amount x original interest paid

Use of the formula is preferable to expanding an FI system to handle multiple scheduled payment dates and calculation procedures.

Thursday, September 25, 2014

Medicare provider Enrollment time frame - How to make it quicker

How you can expedite your enrollment application process

As the Medicare administrative contractor (MAC) for jurisdiction N (JN), First Coast Service Options Inc. (First Coast) is not only responsible for processing Medicare claims but also for processing enrollment applications for providers and suppliers located in Florida, Puerto Rico, and the U.S. Virgin Islands.

The Centers for Medicare & Medicaid Services (CMS) has established the following timeliness standards for contractors responsible for processing enrollment applications within their assigned jurisdictions:

• PECOS Web applications (initial enrollment with no site visit) -- 80% must be processed within 45 days
• Paper-based applications (initial enrollment with no site visit) -- 80% must be processed within 60 days
• Paper-based applications (initial enrollment with site visit) -- 80% must be processed within 80 days
• Paper-based applications (changes to enrollment record or reassignment) -- 80% must be processed within 60 days

First Coast Provider Enrollment Average YTD Processing Times
(Through August 31)
 
PECOS Web Applications
Part A                Part B
 
No development 23 days 31 days
With development 83 days 60 days


Paper Applications
 
No development 36 days 26 days
With development 91 days 57 days

Factors affecting total processing times

Although First Coast processes each enrollment application as quickly as possible, the following key factors may affect the total processing time needed:
• Provider type:
• Part A -- institutional providers
• Part B -- physicians, non-physician practitioners, clinics, and group practices
Shortest processing times: Enrollment applications for Part B providers and suppliers

• Application type:
• PECOS Web application -- an electronic enrollment application submitted through the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) website external link.
• Paper-based application -- a paper enrollment application that is printed and submitted through the mail.
Shortest processing times: PECOS Web applications

• Development required:
• No development -- the enrollment application (paper-based or electronic) is accurate, complete, and is submitted with all required support documentation.
• With development -- the enrollment application (paper-based or electronic) falls into one or more of the following categories:
• Contains errors or inconsistencies
• Incomplete (e.g., missing information or signature)
• Support documentation missing or insufficient

Shortest processing times: Enrollment applications that do not require development

Tips for expediting your enrollment application process
• Use Internet-based PECOS external link
• 25% faster processing time than paper-based enrollment
• Automatic selection of appropriate enrollment form
• Tailored application process
• Fewer errors
• Avoid development requests:
• Review and follow: Documentation requirements for physician and non-physician practitioners.
• Check your application for completeness and accuracy before submission (e.g., required sections completed, inconsistent/incorrect information corrected).
• Submit signed and dated Certification Statement -- all signatures must be original and signed in ink (blue ink preferred). Note: Stamped, faxed, or copied signatures will not be accepted.
• Track your enrollment status online: Use First Coast’s Enrollment status lookup
• Search for all pending applications -- enter your NPI and PTAN
• Search for application status -- enter correspondence control number (CCN) and three-digit tracking number


Friday, September 19, 2014

Medicare deductible, coins - can we collect from patient when patient have secondary insurance

The Medicare Program

The Original Medicare Program, also known as Fee-For-Service (FFS) Medicare, consists of:
• Part A, hospital insurance; and
• Part B, medical insurance.
Under FFS Medicare, eligible individuals may enroll in Part A, Part B, or both Part A and Part B. Most individuals choose
to enroll in both Part A and Part B.
FFS Medicare was expanded in 1973 to include:
• Individuals who are under age 65 with certain disabilities; and
• Individuals with End-Stage Renal Disease.
Two parts were added to the Medicare Program in 1997 and 2006, respectively:
• Part C, Medicare Advantage (MA) (first known as Medicare+Choice); and
• Part D, the Prescription Drug Benefit.

MA is another health plan choice available to beneficiaries. It is a program run by Medicare-approved private insurance companies. Most MA organizations arrange for or directly provide health care items or services to the beneficiary who:

• Is entitled to Part A and enrolled in Part B;
• Permanently resides in the service area of the MA Plan; and
• Elects to enroll in a MA Plan.

The Prescription Drug Benefit provides prescription drug coverage to all beneficiaries enrolled in Part A and/or Part B who elect to enroll in a Medicare Prescription Drug Plan (PDP) or a MA Prescription Drug Plan. Insurance companies or other companies approved by Medicare provide prescription drug coverage to such individuals who live in the Plan’s service area. Medicare beneficiaries who meet certain income and resource limits may qualify for the Extra Help Program, which helps pay for PDP costs.


The Medicaid Program

The Medicaid Program is a cooperative venture funded by Federal and State governments that pays for medical assistance for certain individuals and families with low incomes and limited resources. Within broad national guidelines established by Federal statutes, regulations, and policies, each State:

• Establishes its own eligibility standards;
• Determines the type, amount, duration, and scope of services;
• Sets the rate of payment for services; and
• Administers its own program.

Deductibles, Coinsurance, and Copayments

You must collect unmet deductibles, coinsurance, and copayments from the beneficiary. The deductible is the amount a beneficiary must pay before Medicare begins to pay for covered services and supplies. These amounts can change every year. Under FFS Medicare and MA Private FFS Plans, coinsurance is a percentage of covered charges the
beneficiary may pay after he or she has met the applicable deductible. You should determine whether the beneficiary has supplemental insurance that will pay for the deductible and coinsurance before billing him or her for them.

In some Medicare health plans, a copayment is the amount the beneficiary pays for each medical service.If a beneficiary is unable to pay these charges, he or she should sign a waiver that explains the financial hardship. If a waiver is not assigned, the beneficiary’s medical record should reflect normal and reasonable attempts to collect the charges before they are written off. The same attempts to collect charges must be applied to both Medicare beneficiaries and non-Medicare
beneficiaries. Consistently waiving deductibles, coinsurance, and copayments may be interpreted as abuse.

Thursday, September 4, 2014

Medicare - Payment Ceiling Standards - Payment days

Payment ceilings were implemented for clean claims received by the carrier or FI on or after April 1, 1987. “Clean” claims must be paid or denied within the applicable number of days from their receipt date as follows:

Time Period for Claims Received  Applicable Number of Calendar Days

01-01-93 through 09-30-93   24 for EMC and
                             27 for paper claims
10-01-93 and later   30

All claims (i.e., paid claims, partial and complete denials, no payment bills) including PIP and EMC claims are subject to the above requirements.
Interest must be paid on claims that are not paid within the ceiling period.

The count starts on the day after the receipt date and it ends on the date payment is made. For example, for clean claims received October 1, 1993, and later, if this span is 30 days or less, the requirement is met.

The RAPs submitted by home health agencies under the HH PPS (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not Medicare claims as defined under the Social Security Act. Since they are not considered claims, they (records with type of bill 322 or 332 and dates of service on or after October 1, 2000) are not subjected to payment ceiling standards and interest payment.

See Chapter 24, § 30.2 for definitions of electronic and paper claims for use in application of the Medicare payment floor. See Chapter 1, § 80.2.1.2 for differentiation between electronic claims that comply with the requirements of the standard implementation guides adopted for national use under HIPAA and those submitted electronically using pre-HIPAA formats supported by Medicare. This HIPAA format differentiation applies to the payment floor, but not to the ceiling

Thursday, August 21, 2014

Procedure codes with modifier 22 - Medicare internal issue

An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.

Issue
An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.

Resolution
First Coast is currently identifying the impacted claims and will begin to initiate adjustments on all impacted claims within the next two weeks. Claims having met medical necessity requirements will be changed to an unlisted surgical procedure code (modifier 22 will be appended to the related unlisted surgical procedure) to allow payment above the Medicare physician fee schedule. First Coast began utilizing this process July 11, 2014, for all surgical procedure billed with the 22 modifier that met medical necessity requirements for additional payment.

Status/date resolved
First Coast will began processing impacted claims on August 22,2014.

Provider action
None. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue.

Monday, August 4, 2014

Receipt Date - Medicare definition

The receipt date of a claim is the date the contractor receives the claim (provided the filing is in a format and contains data sufficiently complete so that the filing qualifies as a claim). The receipt date is used to: determine if the claim was timely filed , determine the “payment floor” for the claim , determine the “payment ceiling” on the claim  and, when applicable, to calculate interest payment due for a clean claim that is not timely processed, and to report to CMS statistical data on claims, such as in workload reports.

A paper claim that is received by 5:00 p.m. on a business day, or by closing time if the contractor routinely ends its public business day between 4:00 p.m. and 5:00 p.m., must be considered as received on that date, even if the contractor does not open the envelope which contains the claim or does not enter the claims data into the claims processing system until a later date. A paper claim that is received after 5:00 p.m., or after the contractor’s routine close of business between 4:00 p.m. and 5:00 p.m., is considered as received on the next business day.

A paper claim is considered as received if it is delivered to the contractor’s place of business by the U.S. Postal Service, picked up from a P.O. box, or is otherwise delivered to the contractor’s place of business by its routine close of business time. If the contractor uses a P.O. box for receipt of mailed claims, it must have its mail picked up from its box at least once per business day unless precluded on a particular day by the emergency closing of its place of business or that of its postal box site.


As electronic claim tapes and diskettes that may be submitted by providers or their agents to an FI are also subject to manual delivery, rather than direct electronic transmission, the paper claim receipt rule also applies to establish the date of receipt of claims submitted on such manually delivered tapes and diskettes.

Electronic claims transmitted directly to a contractor, or to a clearinghouse with which the contractor contracts as its representative for the receipt of its claims, by 5:00 p.m. in the contractor’s time zone, or by its closing time if it routinely closes between 4:00 p.m. and 5:00 p.m., must likewise be considered as received on that day even if the contractor does not upload or process the data until a later date. NOTE: The differentiation between HIPAA-compliant and HIPAA-non-compliant in §80.2.1.2 with respect to applying the payment floor, does not apply to establishing date of receipt. Use the methodology described above to establish the date of receipt for all electronic claims.

Paper and electronic claims that do not meet the basic legibility, format, or completion requirements are not considered as received for claims processing and may be rejected from the claims processing system. Rejected claims are not considered as received until resubmitted as corrected, complete claims. The contractor may not use the data entry date, the date of passage of front-end edits, the date the document control number is assigned, or any date other than the actual calendar date of receipt as described above to establish the official receipt date of a claim.

The following permissive exception applies to establishment of receipt date: Where its system or hours of operation permit, a contractor may, at its option, classify a paper or electronic claim received between its closing time and midnight, or on a Saturday, Sunday, holiday, or during an emergency closing period as received on the actual calendar date of delivery or receipt. Unless a contractor closes its place of business early in an isolated situation due to an emergency, the contractor’s cutoff time for establishing the receipt date may never be earlier than 4:00.



A contractor may not make system changes, extend its hours of operation, or incur significant additional costs solely to begin to accommodate late receipt of claims if not already equipped to do so.

The cutoff time for paper claims may not exceed the cutoff time for electronic claims. However, the cutoff time for electronic claims may exceed the cutoff time for paper claims and, indeed, carriers and FIs are encouraged to use this tool where their system and overnight batch run schedules permit. Likewise, at a carrier or FI’s option, it may consider electronic claims received on a weekend or holiday as received on the actual calendar date of receipt, even though paper claims received in a P.O. box on a weekend or holiday would not be considered received until the next business day.

Where a carrier or FI prepares bills for payment for purchased DME because the $50 tolerance is exceeded (see §40.4.1) it establishes any date consistent with its system processing requirements as the receipt date for the second and succeeding bills. It uses the date as close to its payment as possible

Monday, July 21, 2014

Procedure codes with modifier 22


An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule. First Coast Service Options (First Coast) is currently identifying the impacted claims and will begin to initiate adjustment action on all impacted claims within the next two weeks. Note: only claims previously reviewed by our medical staff having met medical necessity requirements to allow above the fee schedule will be adjusted. Providers are asked not to file appeals or call the First Coast call center regarding this internal issue. First Coast apologizes for any inconvenience this issue has caused.
Issue
An internal system processing issue has caused some surgical procedure codes billed with modifier 22 processed on/after January 1, 2014, to not allow any additional money above the fee schedule.
Resolution
First Coast is currently identifying the impacted claims and will begin to initiate adjustments on all impacted claims within the next two weeks. Claims having met medical necessity requirements will be changed to an unlisted surgical procedure code (modifier 22 will be appended to the related unlisted surgical procedure) to allow payment above the Medicare physician fee schedule. First Coast began utilizing this process July 11, 2014, for all surgical procedure billed with the 22 modifier that met medical necessity requirements for additional payment.

Wednesday, July 9, 2014

Electronic vs. Paper Billing - basic overview from Molina insurance

Medicaid  claims  that  are  secondary  to  insurance  or  Medicare  coverage,  including  Medicare HMOs, may be billed electronically either through electronic vendors or through Molina’s web portal.  Contact the EDI Help Desk for access to submitting claims on the web portal.

Medicare Primary Claims 

Many Medicare primary claims crossover to Medicaid automatically from the Medicare Part A and Part B carriers through the Coordination of Benefits Agreement (COBA), but some do not.  Claims that do not crossover, and therefore must be billed separately by providers include:

*** Outpatient claims from Part A Medicare carriers (such as NGS)
*** Long Term Care (LTC) claims from Part A Medicare carriers
*** Anesthesia claims from Part B Medicare carriers (on crossover, these are rejected because
claims are billed in “minutes” not “units”)
*** Claims processed by Medicare HMOs.


All of these types of claims may be billed electronically to Medicaid.  Medicare paid amounts, deductible amounts, and coinsurance amounts are required for Medicare approved services and Medicare Action Codes are required for services denied by Medicare.  This information is re-quired at the claim line level for professional services billed on the 837P format and at the head-er level for institutional services billed on the 837I format.  

***  Allowed amount, paid amount, deductible, and co-insurance information must be billed in the Medicare segments, not the TPL segments, or the claim will not process correctly.  

***  Medicare HMO co-pay amounts are to be billed as deductible.  ***  Claims denied by Medicare HMOs may be billed electronically if the denial is a HIPAA com-pliant denial code or Medicare Action Code (MAC).

***  Denied claims that are not denied with a MAC must be billed on paper with copy of EOMB including the denial reason in addition to the denial code.  

***  All Medicare HMO claims billed on paper must have “Medicare HMO” written on the EOMB to assure correct processing .

Third Party Liability—TPL Primary claims 

Providers must seek reimbursement from private insurance prior to billing Medicaid.  These sec-ondary claims may be billed electronically if the insurance carrier approved the service. Claims that were denied by the primary carrier, or contain denied claim lines, must be billed on paper with a copy of the EOB that includes a description of the denial in addition to the denial codes.

Medicare and TPL Claims 
If a member has Medicare and TPL coverage, claims may be billed electronically if both carriers made payments for the service.

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.



Disclaimer

All the contents and articles are based on our experience and our knowledge in Medical billing. All the information are educational purpose and we are not guarantee of accuracy of information. Before implement anything do your own research. All our contents are protected by copyright laws and guidelines.
If you feel some of our contents are misused please mail me at medicalbilling4u@gmail.com. We will response ASAP.