HealthCare

 Medical billing

Medical billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider(Doctors)

90% people have health insurance in USA. Doctor depends on insurance in USA.

The purpose of medical billing is to ensure that the provider receives fair payment for services rendered. Payment should reflect the services performed and should be received in a timely manner.

Why doctor hire medical billers?

creating claims and getting reimbursed by different insurance companies is such a lengthy process. Doctor save lots of time because of this. Doctor or facilities want to devote their precious time to handle patients only and not waste their time on documentation and other clerical things.

What is the scope in this process

• one of the fastest growing industry in the world
• Recession Free
• experience and knowledge matters
• new learning everyday
• lots of opportunities
• work from anywhere

Basic Term

Patients are the person who visit doctor for any kind of counseling, wellness checkup or to get treated for symptom of an illness

provider are doctor who provides treatment to the patient and charge to their insurance company for payment

Payer are the insurance company who covers patient for any disease or illness and pay to the doctor when a claim arise.

Guarantor./ Subscriber is a person who has the insurance policy s guarantor/subscriber. A patient visiting a doctor may be covered under someone's else policy eg. a child or spouse under husband's policy.

Practice is a place where the services are performed. Sometimes it is same as the name of the doctor.

Patient Demographic information are specific information that needs to create a patients account in doctor's system such as name, sex , address, phone numbers, DOB and insurance information

Primary Care Physician (PCP) is a doctor who see the patient for the 1st time for a disease or illness an refer it to a specialist. Some kind of insurance plans must require a PCP.

Specialist are the doctor who are specialize to treat a particular type of disease or organ. Like cardiologist(Heart), pediatrician(child doctor) or gynecologist(Female doctor) etc.

Referral: some insurance plan requires a referral from the PCP before seen by a specialist. Specialist needs referral from patient's PCP.

Authorization: Insurance companies ask for authorization from the provider before a major treatment, test or surgery. Without taking prior authorization claims can be denied. Doctor must see/ check or confirm that patient's insurance cover the treatment plan or not.

Policy/plan maximum: total amount of benefits receivable to patient or family with a plan or Calendar year.

Patient Responsibilities: certain cost sharing amount by insured that need to be paid directly to the provider during the policy.

Type of patient responsibility

Deductible is a fix amount that need to be paid by the insured or subscriber to the provider before actual benefits starts.

Copayment is a fix amount that need to be paid by the policy holder directly to the provider before each visit/encounter.

Coinsurance : insurance pays certain amount of benefit to the provider on each encounter and assign some % responsibility towards subscriber.

What is CPT, ICD and Modifiers?

CPT (Current Procedural Terminology)

Maintained by AMA(American medical Association)

CPT codes are 5 digit code with descriptive term for reporting medical services and procedures performed by doctors.

The purpose of the terminology is to provide a uniform language that will accurately describe the treatment are diagnostic services provides.

most of these codes are numeric but few have a letter as the first digit

eg electro cardio gram code is 93000

without CPT code claim is not possible

ICD

International classification of diseases

Maintained by WHO

presently 10th revision which is called ICD10.

ICD assigns a specific code to the diagnosis of the condition or disease being treated.

Uniform method so that the insurance, doctor and patients can understand what is being treated in the patient encounter.

These codes are alphanumeric and 3 to 7 character long.

Both CPT and ICD are necessary for claim

ICD is used globally

Modifiers

Modifiers are 2 digit codes. It could be totally numeric, Alphabetic or alpha numeric

These codes can only be used with procedure codes to modify or elaborate, to add more information or specifics to the definition of a procedure code

Most common used modifiers are

RT- right side

LT- left side

59- Distinct Procedure

25- Significant Separately identifiable service

Fee Schedule

is a complete listing of fees used by insurances to pay doctor according to the services performed

NPI

National Provider Identification is a 10 digit unique identification number allotted to doctor and facilities. It is compulsory to obtain NPI for Doctors and facilities.

Tax ID

is number used by IRS for tracking purposes

Provider Network

The network of providers within a geographical area of patients health insurance is In Network Providers

Any provider out of patients geographical area or patients insurance network is called out of network providers

Different types of Insurances

Government insurances:

Medicare

is a federal insurance given by government to their citizen with certain condition like 65 years old, disability or ESRD

Medicaid

coverage is given to those citizen who's income is less then the minimum threshold decided by different states. Basically for low income individuals and families.

Private insurances

Health Maintenance Organization(HMO)

Patients need to choose their PCP which will refer to other specialist if needed. Referral is needed for specialist visits.

Preferred Provider Organization(PPO)

Patients have freedom to choose their provider at the case of higher copays or deductibles

other common plans

Point of service plans - POS hybrid of HMO and PPO

auto/No fault- if expense is more patient can claim this

Worker Comp(compensation)  employer ---> employee

Tricare/Champs etc. Army/arm force

US healthcare process flow

1. Appointment/ scheduling- patients calls to doctors office and book appointments

2. Front Desk - patents comes to the reception and documents scanning and copay collected

3. Demographic entry/ eligibility- necessary information is updated and eligibility confirmed

4. Encounter- patients seen by doctor and treatment/ consultation done

5. medical transcription / scribe - voice file is converted to medical record

6. Medical coding- CPT and diagnosis codes are confirmed and coded

7. Claim Billing - MR/ Superbill handed over to billing team and claims posted in system

8. Copay posting- payments collected at front desk adjusted on accounts

9. Claim Inspection/ Filing- QC is done and claims submitted to insurance

10. EDI corrections- minor issues corrected and clean claims processed

11. Payment / Denial Posting- Received payments posted against claims and denials handed over to AR

12. AR follow up- AR team work on denials ASAP they received along with aging claims

13. patient billing - Necessary balances billed towards patients and statements send on regular intervals

14. Collections- balances moved towards collecting agency if not collected within specific time

Evaluation and management service

New patients is one who has not received any professional services from the provider of the same specialty in the same group within the past 3 years

CPT codes - 99201 - 99205

Patient will remain established if seen by different Doctor but same specialty within a same group/hospital. Patient will become new for a different specialty within a same group/hospital

Established patients is a patient who has received professional services from the provider of the same specialty in the same group with in the past 3 years

CPT codes - 99211 - 99215

Emergency services - unscheduled services received under emergency department of a hospital or immediate medical attention (within 24 hours)

CPT codes - 99281  - 99285

Observation services- Services received under observation department of a hospital to observe the condition of the patient ( with in 72 hours)

CPT codes - 99217-99226

Inpatient Services- services receive under inpatient department of a hospital to treat patient's condition for a longer duration( more than 72 hours)

CPT codes - 99221-99223, 99238-99239(discharge code)

Account Receivable (AR)

What happen when a claim is denied

when a claim is denied by an insurance then it is account receivable department's duty to fulfil the requirements of the payer

there could be several reason when a claim is denied by a payer

working on a denied claims along with the claims which have no correspondence with insurance is called AR

Most common denials

claim is not on file

it means that claim is not received by the payer. below things need to keep in mind when payer is saying claim is not on file

electronic claim-- takes 3-7 day to reach

paper claims takes 15-30 days to reach

if claim has passed these days and still no payment or denial is received then we will call to the insurance company or verify claim status on web portal

if paper claim is not on a file

1. Confirm patient Eligibility

2. Confirm provider's participation status

3. Confirm mailing address

4. Confirm payer ID if any

5. Confirm fax number if any

if electronic claim is not on file

1. See if any EDI rejection

2. Confirm patient eligibility

3. Confirm provider's participation status

4. Confirm mailing address

5. Confirm payer ID

Claim is paid by EFT(electronic fund transfer):

1. Paid date

2. EFT number

3. EFT bulk amount

4. Allowed amount per line

5. Per amount per line item

6. Patient responsibility

    example

    billed $120

    allowed $100

    paid $60

    PR $40

    Contractual adjustment $20

Claim is paid by check:

1. Check issue Date

2. Check Number

3. Check Bulk amount

4. Allowed amount per line item

5. Paid amount per line item

6. Patient responsibility

7. Check cashed date

8. Check mailing address

9. if the check is mailed on different address then we will stop the payment and request for reissue

10. Will take process to update correct address

Claim is paid by Credit Card

1. All payment details

2. Virtual Credit Card number

3. Expire Date

4. CVV number

5. Bulk amount

Commonly used Modifiers

Frequently used modifiers

Modifier 22- Increased Procedural Services(surgical/ procedures codes only)

Modifier 24 - unrelated evaluation and management service by the same physician during a postoperative period

Modifier