Thursday, May 16, 2013
treatment team in which all of its members participate in a coordinated effort to benefit the patient
and the patient’s significant others and caregivers. Interdisciplinary services, by definition, cannot
be provided by only one discipline. Though individual members of the interdisciplinary team work
within their own scopes of practice, each professional is also expected to coordinate his or her
efforts with team members of other specialties, as well as with the patient and the patient’s
significant others and caregivers. The purpose of the interdisciplinary team is to foster frequent,
structured, and documented communication among disciplines to establish, prioritize, and achieve
“MA Organization” means a public or private entity organized and licensed by a State as a riskbearing entity (with the exception of provider-sponsored organization receiving waivers) that is
certified by CMS as meeting the MA contract.
“Medicaid” is a joint Federal and State program that provides health coverage for selected
categories of people with low incomes. Its purpose is to improve the health of people who might
otherwise go without medical care for themselves. Medicaid is different in every state. In Florida,
the AHCA develops and carries out policies related to the Medicaid program.
“Medicaid Fiscal Agent” refers to the State Medicaid Program’s vendor contracted to serve as the
state’s fiscal agent. Some of the fiscal agent functions include: enroll non-institutional providers,
process Medicaid claims, serve as the enrollment broker for Medicaid recipients, and distribute
Medicaid forms and publications.
“Medical Director” means a physician contracted by the organization to provide consultation
regarding member policies and services.
“Medical Group” means a group of PCP and/or Specialist Physicians who:
(1) are formally organized as a partnership or professional corporation;
(2) provide for the diagnosis or direct care and treatment of a medical condition; and
(3) divide their income based on a specified, fixed formula.
“Medically Necessary” shall be determined by CarePlus’ Medical Director and shall include
consideration of whether services:
(1) are appropriate and necessary for the symptoms, diagnosis or treatment of a medical
(2) provide for the diagnosis or direct care and treatment of a medical condition; and
(3) are not primarily for the convenience of the Enrollee, the Enrollee’s attending or
consulting physician, or another healthcare provider.
“Participating Physician” means any physician licensed to practice in the State of Florida who
satisfies the participation criteria established by CAREPLUS and who has entered into a contractual
arrangement with, or is otherwise engaged by, CAREPLUS to provide physician services to
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.
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
Billing and reconciling of accounts
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
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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