Saturday, 14 December 2013

Medical Billing Errors: What can go wrong? What can you do? - 1 - The bill's inception

Medical Billing Errors: What can go wrong? What can you do?

Step 1: The bill's inception
Roughly two dozen people might take action in this stage of the process. It begins
when a patient and surgeon pick a hospital, usually based on where the doctor has privileges, the patient's insurance coverage and the hospital's reputation. Once a surgery date is set, hospital staff begin gathering information about the patient and insurance coverage. This stage ends about a week before the surgery when the patient undergoes medical tests in final preparation for surgery.
The referral
The first information about the patient is entered into the hospital's computer system.
• A surgeon calls the hospital to schedule surgery.

• A hospital scheduler takes information about the patient, checks for available operating room dates, and arranges the surgery based on the surgeon's instructions.
Hospital employees gather a patient's insurance information, inform the patient about any pre-surgery medical tests and talk to the insurance company regarding authorization.
• A hospital preregistration employee, often a nurse, talks to the patient over the phone to obtain insurance information and tell the patient about any advance medical tests, such as blood work and X-rays, that will be necessary.
• Another hospital staff person calls a representative at the patient's insurance company  to confirm coverage, collect benefit information and begin the process of getting insurance authorization for the surgery and any other tests or treatments that require approval.
• Obtaining authorization can be a lengthy discussion, involving the surgeon and one of the insurance company's doctors. Hospital personnel may copy paperwork and deliver it to the insurance company, where a clerk files it in the patient's file for review by an administrator. Sometimes lawyers for the hospital and insurance company become involved if there is a problem with authorization.
Loop: The authorization process may be repeated, either now or later, with discussions about medical necessity and an exchange of paperwork, over different aspects of the patient's care. This may become necessary if a patient's condition worsens and requires additional surgery or treatment.
Even when the insurance company approves surgery and other treatment, it includes a reminder to the hospital that "this will not guarantee payment" because, for example, there might later be a dispute over the care provided, or a patient's insurance coverage information might be inaccurate.
• Based on the insurance authorization, a hospital employee will calculate what the total charges might be, how much might be covered by insurance and how much the patient may pay out-of-pocket. This is the starting point for a discussion about possible financial assistance -- loans, payment plans and charity care.
Pre-admission tests
Typically, a patient goes to the hospital or a doctor's office about a week before surgery for a checkup and pre-admission tests.
• A registration person checks in the patient, confirming personal and insurance information.
• Nurses and other clinical staff check vital signs, draw blood and take X-rays, as ordered by the surgeon.
• Behind the scenes, a technician processes lab tests, a radiologist reads the X-rays, a pathologist assures the accuracy of lab tests, and the surgeon confers with the radiologist.
• A hospital's financial counselor will meet with a patient who has a high-deductible insurance plan or no insurance coverage. The counselor will discuss what the hospital expects the bill to be, based on its model of others who have had the surgery, and what the cost might be to the patient.

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