Sunday, 26 March 2017

Medical Billing Errors

As a medical billing specialist, it’s critically important that you minimize any coding and processing errors as you file claims. Healthcare providers receive the majority of their revenue through the processing of successful claims, so any mistake you make could cost your employer. This course is designed to help you avoid the most common errors and keep denied and rejected claims at a minimum.

Understanding the Difference Between a Denied and a Rejected Claim

First, you need to know the difference between a denied claim and a rejected claim. A denied claim is one that has been determined by an insurance company to be unpayable. Typically, insurance companies explain the reasons in the Explanation of Benefits (EOBs) attached to the claim. Claims are often denied because of common billing errors or missing information, but can also be denied based on patient coverage. Denied claims can be appealed and reprocessed in some cases.
rejected claim has been rejected because of errors. An insurance company might reject a claim because a medical billing specialist incorrectly input patient or insurance information. Once a medical billing specialist amends the errors on a rejected claim they can resubmit it for processing with an insurance company.

Common Errors Made When Filing a Claim

It is easy to overlook parts of a claim when you’re processing many in a given day. But if you can identify some of the more common mistakes medical billing specialists make, you can try to avoid them. Here are some of the most common mistakes made when filing a claim:
  • Entering incorrect information for the provider (name, address, contact information, etc.)
  • Entering incorrect information for the patient (name, sex, date of birth, insurance ID information, etc.)
  • Entering incorrect information for the insurance provider (policy numbers, address, contact information, etc.)
  • Inputting the wrong codes or confusing codes such as CPT codes, point of service codes, or ICD-9-CM codes
  • Entering too few or too many digits for ICD-9-CM codes
  • Inputting mismatched treatment and diagnostic codes
  • Forgetting to input codes at all for services performed by a physician or another healthcare official
Again, every piece of information on a claim has to be accurate in order for it to be processed correctly. It is particularly important to make sure the correct codes are used. Be sure to familiarize yourself with all the relevant codes as well as patient, provider, and insurance information prior to filing a claim.
Other common billing errors include the following:
  • Not having access to EOBs on denied claims: Sometimes an insurance company may forget to attach the EOB to a denied claim. In these cases, you won’t know the reason the claim was denied because the insurance company didn’t provide it at all or it was mistakenly sent to another provider. You can minimize problems with the EOB by keeping track of denied claims as soon as you receive them from insurance companies.
  • Not verifying a patient’s insurance coverage: A patient’s health insurance can change at any time, sometimes without the patient knowing it. As a medical billing specialist, part of your job is to verify insurance coverage.
  • Duplicate billing: Duplicate billing is an issue that occurs when you bill for the same service more than once. This might happen if more than one person at a provider’s office reports that a patient received services without checking whether or not those services had been paid for. The best way to avoid duplicate billing is for you to be extra vigilant about suspicious entries on a patient’s superbill and to communicate your concerns to a physician about them.
Some billing errors are simply beyond your control including the following:
  • Upcoding: Upcoding occurs when physicians or medical coders enter codes into a patient’s superbill for services not received. Typically this is done to inflate the total amount a patient owes for receiving care at a healthcare provider. Upcoding is illegal and can lead to fines and criminal prosecution.
  • Undercoding: Undercoding occurs when a physician or a medical coder leaves out codes from a patient’s superbill or codes them for less treatment than they actually received. Healthcare providers might undercode for healthcare services in an attempt to avoid audits or to minimize a patient’s cost. Undercoding is also illegal and can have legal repercussions.
  • Sloppy documentation: Medical billing errors can also arise when physicians or other healthcare providers turn in sloppy documentation to medical billing specialists. A physician might have illegible handwriting, for example, making it hard to assign codes and bill for a patient’s healthcare. A physician’s documentation may also cause you to inadvertently undercode a patient’s bill.

How to Catch and Correct Errors Early

To avoid common medical billing: stay vigilant about simple mistakes on your end, be thorough when reviewing a patient’s superbill, and consult with your physician whenever you have questions about what should or shouldn’t be billed for. Most medical billing errors can be avoided well before claims are sent for processing with an insurance company, and it’s up to you to keep the claims moving through the system quickly and accurately. Here are a few tips to help you stay on track:
  • Coordinate with everyone at the provider’s office: You aren’t the only person responsible for the information you in a claim. The physician who administered the actual healthcare and the personnel who collected a patient’s co-pay and insurance information also contributed to the superbill. So if you have any concerns about a claim, you can check with them to work out any issues before submitting the claim.
  • Double-check patient and insurance information before filing a claim: Entering patient and insurance information incorrectly is one of the easier mistakes to avoid, but they still happen. The strategy for avoiding this mistake is simple: double-check your work.
  • Study billing and coding trends: You can guard against coding mistakes by staying up to date on the latest medical billing codes. Medical billing codes change over time to accommodate modifications in healthcare regulations, newfound illnesses, and new treatments for illnesses and conditions. Be sure to study new codes and billing procedures as they become available.
  • Follow up on claims: You can avoid and anticipate errors by following up on claims filed with insurance companies. A representative working on the claim for the insurance company might be able to tell you of any errors they find on their end, and thereby provide you with an opportunity to resubmit a claim before it gets denied.

Thursday, 23 March 2017

Types of Health Insurance Coverage

There are a number of ways in which health insurance carriers provide coverage. Health insurance coverage can be quite complex, as it involves the coordination between a healthcare provider, the health insurance provider, and the actual person receiving care. As a medical billing specialist, you will need to be especially aware of the role that each party plays in these coverage plans as you process claims. Some of the methods of coverage include managed care, indemnity policies, and high-deductible plans.

Managed care

Managed care is the most common form of health insurance coverage. Managed care coverage is administered by organizations that contract with healthcare providers to create an active network of participating providers. The three main components of managed care are preferred provider organizations, health maintenance organizations, and point of service plans.
  • Preferred provider organizations (PPOs): PPOs operate off a list of preferred healthcare providers that patients can choose from for their coverage. Patients save the most money on their healthcare plans by selecting the preferred providers affiliated with a PPO. Providers on the preferred list are considered “in-network,” while those not on the preferred list are “out-of-network” providers. Sometimes an insurance carrier will not cover a person who receives treatment from an out-of-network provider, though PPOs tend to have more coverage options for out-of-network providers than HMOs.
  • Health maintenance organizations (HMOs): HMOs are groups of physicians, medical facilities, and healthcare services that work to keep patients under the care of providers within their network. Healthcare providers in HMOs coordinate a patient’s healthcare decisions and suggest a suitable hospital for urgent care. Because of the close-knit healthcare community in HMOs, members enrolled with these organizations tend to have limited provider options. The upside to HMO membership is that patients tend to pay less in deductibles and receive higher quality medical care coverage at facilities within the HMO network.
  • Point-of-service Plans: Point-of-service plans form a hybrid between PPOs and HMOs. As with HMOs, point-of-service plans allow you to select physicians and services from within a dedicated network of providers. Unlike HMOs, you have the option of coverage for care received from out-of-network providers. Note that patients in point-of-service plans have to get a referral before being covered by out-of-network providers, and they likely have to pay a deductible. Some HMOs offer point-of-service plans to people who want more options with their healthcare coverage.

Indemnity policies

Indemnity policies, or fee-for-service insurance, allows people the freedom to choose whatever healthcare provider they want and receive some form of coverage for these services. Patients covered by an indemnity policy can go to any healthcare provider and receive care, even when traveling across state lines.
The caveat to indemnity policies is that patients are typically required to pay a deductible or out-of-pocket fee before they start to receive coverage. This means patients with an indemnity policy can able to receive emergency room care at a hospital of their choosing, but they might have to pay a sizable deductible (ranging from a few hundred to several thousand dollars) before insurance carriers will pay for their care. Many indemnity policies allow patients to choose how much they pay for their deductible, and that amount is commensurate with the level of coverage they receive from insurance carriers.

High-deductible plans

High-deductible plans have low premiums and high deductibles, which make them enticing to those who don’t want to pay for health insurance up front. High-deductible plans may be a preferable coverage option for people with a clean bill of health who don’t anticipate requiring any medical services in the near future. Of course, when those with a high-deductible plan do require care, they are responsible for covering the cost of their care until they reach the predetermined deductible. However, people with high-deductible plans don’t have to pay the deductible before receiving coverage for preventive care services. Some people opt to enroll in health savings accounts or health reimbursement arrangements to help mitigate the potential costs of high-deductible plans:
  • Health savings account (HSA): HSAs allow people to pay for certain medical expenses (including expenses incurred before meeting a deductible) using nontaxed funds. Patients build their savings in an HSA by contributing a portion of their paycheck or other earnings on a regular basis. Funds that remain at the end of the year can often be rolled over to the next year. Furthermore, people with an HSA keep their funds once they leave a job and can continue contributing to their HSA with their next employer. However, there is a limit to the amount of earnings that can be contributed to an HSA.
  • Health reimbursement arrangement (HRA): HRAs are different from HSAs in that employers, not the employees, contribute funds to the account that is used to offset healthcare costs. Employees lose their HRA funds if they leave or are terminated from a company, and any funds unused by the end of the year are no longer accessible in the following year.

Monday, 20 March 2017

Health Insurance Providers

Health insurance providers come in many forms, but they can be reduced to two major groups: privately owned companies and programs operated by the government. As a medical billing specialist, you should be well versed in the differences between these providers and the plans that they offer.

Government Insurance Providers

The federal and state governments fund and operate several government insurance providers. Many of the government-operated insurance programs are specifically designed to cover a certain part of the population, such as veterans, the elderly, or low-income persons. Below are some of the government insurance providers that you will encounter when filing claims:
  • Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA): This government program covers certain healthcare costs for dependents of veterans who are permanently disabled due to injuries or conditions suffered during service, as well as dependents of veterans who died during service.
  • Consolidated Omnibus Recollection Act (COBRA): COBRA was a law passed by the federal government to serve as a safety net for individuals recently terminated by a company that provided health insurance. Under COBRA, terminated employees and their dependents can still receive health insurance from their previous company’s healthcare plan for up 18 months, and up to 36 months if they are disabled.
  • Medicare: Medicare is a program started by the federal government to provide healthcare coverage options for persons over 65 years old, as well as younger people with disabilities. The Medicare program itself is broken up into several parts, each of which provides insurance that covers certain aspects of healthcare (such as prescription drug coverage) to eligible individuals.
  • Medicaid: Medicaid is a program started by the federal government to offer healthcare coverage to low-income individuals. The costs of the Medicaid program are divided between the state and federal governments, a complication you will need to be aware of as you file claims. Note that all states have their own version of a Medicaid program, though they all must meet minimum requirements of care as established by the federal government.
  • Children’s Health Insurance Program (CHIP): This program provides health insurance to children of families who can’t afford private coverage and whose incomes are too high to receive Medicaid coverage. CHIP is jointly funded by state and federal governments just like Medicaid, and each state has a different interpretation of its program.
  • TRICARE: This healthcare program provides insurance to active-service members and their families, retired military personnel and their families, and the survivors of deceased service members. TRICARE (formerly known as Civilian Health and Medical Program of the Uniformed Services, or CHAMPUS) is funded and run by the federal government.
  • Worker’s Compensation Insurance: This type of health insurance is available for employees who suffer injuries or illnesses while performing their regular work duties. Worker’s compensation insurance is required by law in most states.
There are other federal and state insurance programs available to those who are eligible, but those mentioned above make up the majority that you will encounter as a medical billing specialist. 

Commercial Insurance Providers

Commercial insurance providers are private insurance companies that contract with businesses or individuals to help cover healthcare costs according to criteria set forth in a formal health plan. Private health insurance plans typically require that the company or the individual receiving coverage pay a predetermined deductible or a monthly premium before benefits take effect.
Commercial health insurance providers offer plans that can be sold individually or collectively as a group plan. Plans offered by commercial insurance providers range in price and in the scope of services covered. Coverage from commercial providers depends on a number of factors, including a patient’s personal medical history, family medical history, and the amount of money the patient (or the sponsoring employer) is willing to spend on premiums, co-pays, and deductibles.
Most Americans who have health insurance have plans with private insurers. According to a recent survey by the Center for Disease Control, nearly 64.2% of insured Americans have private health insurance. Commercial insurance providers include companies like Aetna, United Health Care, and Prudential.

Key Differences Between Government and Commercial Insurance Providers

It is important to keep in mind that commercial insurance providers are for-profit institutions whose success depends on the premiums that they receive from insured businesses and individuals. As such, commercial insurance providers are likely to provide coverage for people who have an uneventful medical history rather than someone with a long history of medical problems. Commercial insurance providers make money by avoiding as much risk as possible in their health plans. If a private insurance company mostly covers people who need constant medical attention for chronic illnesses or conditions, that company would be in danger of offsetting the revenue generated by its premiums.
Government insurance providers are a reliable alternative for certain people denied coverage by commercial insurance providers. Because government insurance providers aren’t interested in generating a profit from premiums, they can afford to cover “riskier” people.

Friday, 17 March 2017

Processing Claims for Medicare and Medicaid

Know how to handle claims through these government healthcare programs.

Medicare claims

As a medical billing specialist, Medicare claims you file on behalf of the provider are sent directly to nearby MACs for processing. MACs typically take around 30 days to process each claim they receive.
Part A claims: Medicare pays the provider directly. Any deductibles, co-pays, or other fees that apply after Medicare pays the provider must be satisfied by the patient.
Part B claims: Medicare pays either the provider or the patient for care covered by the plan, which depends on who accepts assignment of the claim. If the provider accepts assignment of the claim, Medicare will pay them for 80% of the approved amount. The remaining 20% will be paid to the provider by the patient. If the provider does not accept assignment of the claim Medicare will pay the patient the approved amount for care received, and they will then pay the provider.

Medicaid claims

Processing billing for Medicaid claims can be trickier than those filed under Medicare because Medicaid claims must adhere to both federal and state guidelines. Providers who participate in Medicaid must meet these guidelines, and as a medical billing specialist you should be aware of any discrepancies between federal and state guidelines as you process claims. For example, a provider must adjust the remaining balance once meeting any applicable charges for a co-payment or deductible and after Medicaid has paid what they are allowed to pay under the Medicaid fee schedule.
Note also that Medicaid is officially the payer of last resource for a claim, meaning that if a person has any other health coverage for services rendered, those institutions should be billed before Medicaid.

Thursday, 16 March 2017

Medical Billing for Medicare

Medicare functions as a single-payer healthcare system that pays insurance companies on behalf of people enrolled in its various programs. It’s up to medical billing officials to submit claims to appropriate MACs for processing after a person has received care covered by their Medicare plan.
Your duties as a medical billing specialist include inputting information from a provider’s superbill into compatible medical billing software. This includes provider information, patient information, information regarding treatment the patient received, and any relevant medical codes. Once you’ve input the necessary information into the medical billing software, you will either print out a CMS-1500 claim form for submission via mail or you will submit another claim form electronically to MAC for processing. As you file claims associated with Medicare, you will need to input medical codes similar to those you would use for Medicaid claim forms including CPT, ICD-9-CM, and place of service codes.
In order to properly understand how to file claims associated with Medicare coverage, consider the separate parts of the Medicare healthcare program.

Part A: medically necessary services

You will process claims associated with Part A of Medicare (medically necessary services) if you’re a medical billing specialist working with hospitals, clinics, and other facilities that offer inpatient care. You file Part A claims on behalf of your provider using the UB-04 medical claim form (also known as the CMS-1450 form). The UB-04 is the uniform institutional provider hardcopy claim form accepted for billing third-party providers. It is also the only hardcopy claim form that CMS accepts from institutional providers such as hospitals or skilled nursing facilities. When filing the UB-04 form, you should note that not all payers are required to complete the same data fields. Do your research to determine what fields are appropriate for each claim.

Part B: preventative care

As a medical billing specialist working for an outpatient healthcare provider, you will usually process claims associated with Part B of Medicare (preventative care). You file Part B claims using the CMS-1500 form, which is the standard claim form used by healthcare providers to billing Medicare carriers.
These forms must be purchased from legitimate sources other than the CMS, like the National Uniform Claim Committee (NUCC), which is responsible for updating and maintaining the CMS-1500. Be sure to check the guidelines for printing and preparing CMS-1500 forms before you process any claims. Note that the CMS-1500 form can also be used to bill some state Medicaid programs.

Parts C and D: to be filed separately

Claims related to Parts C and D of Medicare are relayed through a private insurer and should never be filed through Medicare. You won’t file Medicare claims with Parts C and D because private health plan carriers have agreements with Medicare to receive a certain amount per member every month. Part D of Medicare coverage may change depending on the person receiving care because coverage depends on the drugs involved. Some drugs aren’t covered by Part D at all. Thus claims filed through Parts C and D of Medicare should be treated like any other claim handled through a private health plan carrier.

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