Sunday, 23 July 2017

Following Procedures

Medical administrative work requires following a set of procedures. Some procedures involve administrative duties, such as entering data, updating patients’ records, and billing insurance companies. Other procedures are done to comply with government regulations, such as keeping computer files secure from unauthorized viewing. In most offices, policy and procedure manuals are available that describe how to perform major duties.

For most procedures, medical assistants work in teams with both licensed medical professionals and other administrative staff members. Providers include physicians and nurses as well as physician assistants (PAs), nurse-practitioners (NPs), clinical social workers, physical therapists, occupational therapists, audiologists, and clinical psychologists. Administrative staff may be headed by an office manager, practice manager, or practice administrator to whom medical assistants, patient services representatives or receptionists, and billing, insurance, and collections specialists report. 

Communicating with Physicians and Patients  
Communication skills are as important as knowing about specific forms and regulations. Using a pleasant tone, a friendly attitude, and a helpful manner when gathering information increases patient satisfaction. Having interpersonal skills enhances the billing and reimbursement process by establishing professional, courteous relationships with people of different backgrounds and communication styles. Patients may need help with their questions about insurance reimbursement and the health care claim process. Patients also need assistance when problems with payments arise. Effective communicators have the skill of empathy; their actions convey that they understand the feelings of others.

Equally important are effective communications with physicians, other professional staff members, and all members of the administrative team. Conversations must be brief and to the point, showing that the speaker values the provider’s time. People are more likely to listen when the speaker is smiling and has an interested expression, so speakers should be aware of their facial expressions and should maintain moderate eye contact. In addition, good listening skills are important.  

Wednesday, 19 July 2017

Working with Medical Insurance

The trillion-dollar health care industry—including pharmaceutical companies, hospitals, doctors, medical equipment makers, nursing homes, assisted-living centers, and insurance companies—is a fast-growing and dynamic sector of the American economy.

Spending on health care in the United States continues to rise. Advances in medical technology improve health care delivery but are expensive. Health care reform legislation requires insurance coverage for a growing number of people. Perhaps most importantly, the aging American population requires more health care services. Average life expectancy is increasing and a larger percentage of the population is over age 65. Older people need more health care services than do younger people. Two-thirds of Americans over 65 and three-quarters of those over 80 have multiple chronic diseases, such as diabetes, hypertension, osteoporosis, and arthritis. 

Since medical costs are rising faster than the overall economy is growing, more of everyone’s dollars are spent on health care. Federal and state government budgets increase to pay for medical services, employers pay more each year for medical services for their employees, and patients also pay higher costs. These rising costs increase the financial pressure on physicians’ practices. To remain profitable, physicians must carefully manage the business side of their practices. Knowledgeable administrative medical office employees are in demand to help. 

Medical administration tasks in medical offices may be handled by employees who have various educational backgrounds and work experience, such as administrative medical assistants, medical assistants, medical billers, patient services specialists, and receptionists. (In this text, for simplicity, the term medical assistant includes all of these administrative medical employees.) Their effective and efficient work is critical for the satisfaction of the patients—the physician’s customers—and for the financial success of the practice. 

To maintain a regular cash flow—the movement of monies into or out of a business—specific tasks must be completed on a regular schedule before, during, and after a patient visit. Managing cash flow means making sure that sufficient monies flow into the practice from patients and insurance companies paying for medical services, referred to as accounts receivable (AR), to pay the practice’s operating expenses, such as for overhead, salaries, supplies, and insurance—called accounts payable (AP) . Tracking AR and AP is an accounting job. Accounting, often referred to as “the language of business,” is a financial information system that records, classifies, reports on, and interprets financial data. Its purpose is to analyze the financial condition of a business following generally accepted accounting principles. The practice accountant sets up accounts such as AR, AP, and Patient Accounts for all aspects of running the practice and then prepares financial statements that show whether the cash flow is adequate. These statements are monitored regularly to see if revenues are sufficient or need improving.

 For this reason, revenue cycle management (RCM)—acting to ensure that the practice receives all appropriate payments from both insurance companies and patients, and gets them on time—is critical to practice success. Medical assistants have an important role in revenue cycle management. They help to ensure financial success by (1) carefully following procedures, (2) communicating effectively, and (3) using health information technology—medical billing software, electronic health records, Microsoft Office, and the Internet—to improve efficiency and contribute to better health outcomes.

Saturday, 15 July 2017



accounts payable (AP) 
accounts receivable (AR)
cash flow 
covered services 
electronic claim (e-claim) 
electronic health record (EHR)
health care claim 
health information technology (HIT) 
health plan 
indemnity plan 
managed care 
managed care organization (MCO)
medical assistant 
medical billing cycle 
medical documentation and billing cycle 
medical insurance 
 medically necessary 
noncovered (excluded) services 
out-of-pocket PM/EHR 
practice management program (PMP)
procedures provider 
 remittance advice (RA) 
revenue cycle management (RCM) 
third-party payer 

Patients who come to physicians’ practices for medical care are obligated to pay for the services they receive. Some patients pay these costs themselves, while others have medical insurance to help them cover medical expenses. Administrative staff members help collect the maximum appropriate payments by handling patients’ financial arrangements, billing insurance companies, and processing payments to ensure both top-quality service and profitable operation.

Tuesday, 11 July 2017

Proprietary software

“ Controls should be established to prevent unauthorized and potentially inaccurate computer changes from being incorporated into [the medical billing system]....”

Software developed for a single individual or a small group probably posses the greatest risk of financial harm to the Medicare program. In some cases, the number of people involved in developing and implementing proprietary software is limited to one or two individuals. This reduces the likelihood that someone will see and correct programming that produces erroneous claims. 

The degree of risk associated with proprietary software is directly related to the number of individuals involved and the checks and balances used during development of software. A recent qui tam suit against a billing company revealed that the owners of the company configured their proprietary software to generated erroneous claims.6 They accomplished this by manipulating and using legitimate information about patients and providers already available in their system. The company agreed to pay $1.5 million to resolve allegations that the company defrauded Medicare and other health care programs.  

In another case, emergency room physicians contracted for billing services from a hospital.7 The physicians were unaware that the hospital had purchased and designed billing software that automatically upcoded the services of the physicians. The physicians were paid based on the codes they provided to the hospital billing department. The hospital kept the higher payment generated from upcoding. The hospital and physicians agreed to a civil settlement and paid more than $600,000 to settle the case.

Billing Medicare has become a complex endeavor. The sheer number of diagnostic codes, procedure codes and other coding requirements increase the chance of billing error. Automation helps physicians, and other Medicare providers, manage data. It helps ensure that claims for reimbursement will meet Medicare standards for claims acceptance. The same tools used to ensure accurate billing can also be misused to maximize reimbursement and to submit false claims. 

The HCFA needs to evaluate its electronic claim safeguards and PECOS is a step in the right direction toward ensuring that only agencies authorized by a provider can submit claims. As further work is done in this area, HCFA may want to consider: 

  •  Identifying and registering all clearinghouses and third-party billers. The Internal Revenue Service requires preparers of tax returns to identify themselves. Medicare should require claim preparers to do the same. This would provide an audit trail and ensure that claims enter the Medicare system from authorized sources. 
  •  Improving safeguards to ensure that electronic claims are accepted only from authorized sites and terminals. Passwords and new technologies, such as caller identification, can be used to ensure that claims are received and processed only from known terminals. 
  •  Educating the provider community concerning their liability for erroneous claims submitted to Medicare using their provider number(s). The HCFA currently relies on provider reviews of remittance notices to identify misuse of provider numbers. These notices can be re-routed to a billing company, or another address, and providers may never see them. Providers should be made aware of their responsibility to review remittance notices.  

Friday, 7 July 2017

Informational Software

“...many operations previously performed manually are automated within [informational medical billing] system software.”

Medical billing software has become more sophisticated, and many operations previously performed manually are now being linked to, or included in, billing software packages. Unlike basic software which relies heavily on user knowledge, judgement and entry skills, informational software uses internal data bases and dictionaries to increase productivity and minimize the number of entry errors.3 Medical billing software packages with no, or limited, data base and dictionary capabilities can be linked to other independent software packages specifically designed to meet a particular billing need. For example, software capable of recalling all diagnosis codes (ICD-9 codes) and all procedure codes is available. Related software packages can be linked to billing software or used to create dictionaries containing limited coding information. 

Another characteristic of informational billing software is the ability to recall patient and provider identifying information and in some cases the service items on the last claim submitted for payment. The user can then update the last bill by merely adding line items to the claim or deleting them. Adding line items to a claim is facilitated by the software’s data bases or dictionaries. As the user enters a code or service number, the system’s software automatically recalls the CPT codes, charge information and other pertinent information stored in the software’s data base(s). If the procedure code or diagnosis code is not in the software’s dictionaries, the software can be configured to accept additional codes and information or it can limit choices to those in the system. With a few keyboard entries the user can create a new claim using new information and information already stored within the system.

Like basic medical billing software, informational billing software also provides information to the user about validity tests, completeness tests, logic tests and other program controls established by the software developer. It can be linked to other software packages designed to analyze claim information to see if it will pass Medicare and private sector scrutiny. It can edit services entered on a claim and notify the user of invalid code combinations, missing diagnosis and other errors that might prevent the timely processing of the claim. The user draws upon information provided by the system, and outside the system, to resolve errors identified by the software.

Vulnerabilities inherent in information software are more likely to stem from manipulation of software configuration and data bases and not the software programs themselves. Limited procedure coding options may steer claim decisions to higher valued procedure codes and encourage the use of diagnostic codes not supported in the patient’s medical record. Ultimately it is the software user’s choices and decisions and not the software that affects the accuracy of claims submitted to Medicare. Improperly configured informational software data bases and dictionaries can be misused. Misuse increases the probability of error and exposes physicians and other users to potential payment errors.  

 Interactive Software
Vendor software packages usually contain many options that can be used to generate a claim. These software packages can be vulnerable to misuse and inadvertent error.

Interactive medical billing software represents the state-of-the-art in software billing. Interactive software expedites data entry and offers users several options to facilitate claims processing. Bar coding is one option available that reduces input error. Other options include electronic links to an office laboratory or other medical services that allow the user to obtain billing information directly from the laboratory, other data files and other office areas. Interactive software recalls patient, provider and last claim information. The software recognizes multiple insurance payers and the different coding rules and codes used by them. Interactive systems can be programmed to link procedure codes to ensure the right code is submitted to each of the patient’s insurers. For example, a private insurance carrier may require the use of procedure code 36145 when billing for venipuncture. Medicare requires G0001 for the same service. The software automatically selects the right code for each insurer. 

Interactive systems usually do more than give feedback that something is missing on a claim. They provide information to help the user correct the problem. For example, when the user enters an invalid CPT code, the interactive medical billing software advises that an invalid CPT was entered. The software may produce a list of valid codes in the system and prompts the user to select one of the codes or enter a new code. Some systems also show the expected payment for each code. 

Each software user decides what “prompts” will be in the system. These prompts may also provide feedback as to how coding will affect reimbursement, show other coding options and the expected Medicare reimbursement for each option. The user can accept a system prompt, bypass it or modify it. Interactive systems reduce entry errors. The software uses a form of artificial intelligence to “learn” from past claims activity which services will be paid or denied. Providers can also purchase additional software that analyzes their claim information for compliance with Medicare’s correct coding initiative. Software manufactures and others are also working to identify HCFA’s black box edits.4 As the body of knowledge about these edits increases, software applications will no doubt be not far behind. What distinguishes interactive software from other medical billing software is its ability to provide the user with information and the likely consequences (no pay, more pay, less pay) of their decision. 

Data bases and dictionaries that restrict user choice of diagnostic codes, CPT codes, place of service codes and other claim data can contribute to payment errors.5 The system may be programmed with default diagnostic codes. Whenever medical services or tests are billed, the default diagnostic code can automatically be added to the claim to ensure that the service, procedure or supply billed to Medicare will avoid Medicare safeguards and be paid. The end result produces claims that are flawlessly executed; unfortunately, the medical record may not support the services billed to Medicare. Diagnostic information must be in the patient medical record for the date of service. If it is not, Medicare will recover any money paid in error. 

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