medical_billing_terms

CMS 1500​ - Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500's. The form is distinguished by it's red ink.

Coding​ - Medical Billing Coding involves taking the doctor's notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment. 

COBRA Insurance​ - This is health insurance coverage available to an individual and their dependents after becoming unemployed - either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It's typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986. 

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.

Coinsurance​ - Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%. 

Collection Ratio​ - This is in reference to the providers accounts receivable. It's the ratio of the payments received to the total amount of money owed on the provider's accounts.

Contractual Adjustment​ - The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company. 

Coordination of Benefits​ - When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary. 

Co-Pay​ - Amount paid by patient at each visit as defined by the insured plan. 

CPT Code​ - Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot. 

Credentialing​ - This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance company networks. 

Credit Balance​ - The balance that's shown in the "Balance" or "Amount Due" column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund. 

Crossover claim​ - When claim information is automatically sent from Medicare the secondary insurance such as Medicaid. 

Date of Service (DOS)​ - Date that health care services were provided. 

Day Sheet - Summary of daily patient treatments, charges, and payments received.

Deductible​ - amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor's visits or prescriptions to reach the deductible. 

Demographics​ - Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

DME - Durable Medical Equipment​ - Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc. 

DOB​ - Abbreviation for Date of Birth

Downcoding​ - When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment. 

Duplicate Coverage Inquiry (DCI)​ - Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists. 

Dx​ - Abbreviation for diagnosis code (ICD-9 or ICD-10 code). 

Electronic Claim​ - Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.

Electronic Funds Transfer (EFT)​ - An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

 E/M​ - Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patient's treatment needs. 

EMR​ - Electronic Medical Records. This is a medical record in digital format of a patient's hospital or provider treatment. 

Enrollee​ - Individual covered by health insurance

Training for Medical Billing and Coding

MEDICAL BILLING AND CODING TRAINING COURSES

medical billing for you

It's important to choose a well-rounded medical billing and coding training program at a quality school. In addition to academic knowledge, however, you'll also need plenty of real-world practice. So you should also look for a program that allows you to complete an externship in a hospital, doctor's office or other medical setting. This hands-on learning experience will be invaluable as you start your career.

Medical billing and coding training courses range from basic keyboarding to anatomy and physiology. Each course challenges you in different ways. Here is a list of common medical billing and coding courses you might see in a diploma program.

GETTING MEDICAL BILLING AND CODING TRAINING ONLINE

Medical billing and coding is a great degree to get online, since a lot of the coursework requires a good deal of memorization. Studying and testing at your own pace can be less intimidating for some students than being in a classroom.

Read some interesting pointers that may help you decide whether an online medical billing and coding degree is for you.

MEDICAL BILLING TRAINING: TIME TO COMPLETION

There are several types of medical billing and coding degrees to choose from:

• Certificate and diploma programs, which generally take nine months to one year to complete.
• Associate's degree programs last two years and provide other general education curriculum.
• Bachelor's programs are 4-year programs and also provide a general liberal arts curriculum.

MEDICAL CODING SCHOLARSHIPS & FINANCIAL AID

The American Health Information Management Association Foundation of Research and Education (FORE) offers scholarships to outstanding undergrads. You may also find medical billing and coding scholarships being offered at the schools to which you apply.

MEDICAL BILLING AND CODING TRAINING SCHOOL ACCREDITATION

Regardless of where you complete your medical billing and coding training, make sure your school is accredited by one of the following accrediting bodies if you want medical billing and coding or health information technician certification:

• Commission on Accreditation of Allied Health Education Programs (CAAHEP)
• American Health Information Management Association (AHIMA)
• Regional accrediting bodies

MEDICAL BILLING AND CODING SALARY

Once you've put in the hard work and completed your medical billing and coding training, you'll want to earn the best salary possible. A lot will depend upon location and the environment you choose, so read up on the facts by visiting our medical billing and coding salary page.

Overall Medical billing process

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.

Insurance verification

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

Insurance enrollment

Charge entry

Insurance verification

Billing and reconciling of accounts

Payment posting

Insurance authorization

Medical coding

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


* Refunds

How to avoid Medical Coding Training Scams?

medicalbillingforyou.blogspot

WHAT TO KNOW BEFORE BUYING MEDICAL BILLING CODING SOFTWARE

You may be wondering why you should spend your time and money on a medical billing degree or certificate program when you see ads every day that claim you can install medical billing coding software and earn thousands of dollars per month working from home as a medical billing and coding specialist.

As you may have suspected, the vast majority of these "business opportunities" are scams. According to the Federal Trade Commission, which has filed charges against many of these companies, "few consumers who purchase a medical billing business opportunity are able to find clients, start a business and generate revenues—let alone recover their investment and earn a substantial income."

MEDICAL BILLING IS A SKILLED PROFESSION

While many companies will want to convince you that starting a medical billing business is as simple as installing some software on your computer and letting local doctors know you're open for business, you should know that medical billing involves much more than simple data entry. As a medical billing specialist you'll need to have the following knowledge and skills:

• Ability to fill out several types of complex insurance claim forms
   
• Knowledge of insurance guidelines, procedures and claims submission process
   
• Ability to analyze Explanation of Benefits (EOB) forms to ensure that insurance companies have properly assessed and paid for charges
   
• Ability to follow up with insurance companies and patients to ensure that bills are paid in a timely manner
   
• Ability to generate accounts receivable reports for clients

GET AN EDUCATION IN MEDICAL BILLING AND CODING

In addition to the above skills, you should strongly consider enrolling in a program that will educate you in both medical billing and coding. It's common for schools to combine both skill sets in one program, given that medical coding—the process of translating the information in a patient's charts into a set of coded, billable items—is essentially the first step in the billing process. Although it's possible to specialize in either medical billing or medical coding, you'll be far more marketable if you know how to do both.

MEDICAL BILLING BUSINESS REQUIREMENTS FOR SUCCESS

Medical billing specialists are responsible for getting doctors paid. This being the case, there aren't many medical practices willing to hand their accounts receivable over to an individual with minimal expertise. With a degree or certificate in medical billing and coding, a year or two of experience under your belt, and a list of personal contacts in the industry, you'll be prepared to start your medical billing business the right way.

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Insurance calling process 2013

How to call insurance

The Night caller or AR caller (India) will call the insurance companies based on the patient accounts given by the Analyst (If it is in India, In US both persons are same). Caller will documents the telecom conversion in those respective patient accounts; also caller will send a report to the A/R Analyst on daily basis.

A/R caller will calls insurance companies over the telephone in order to get the reimbursement in a timely fashion. Let us see how the A/R caller calls the

Patient Demographic sheet

Patient Demographics sheet contains all the basic information about an individual or patient.  Patient demographics have been classified into five major headings


Patient Information
Patient employer information
Patient guarantor information
Physician information
Insurance information. 


Patient Information consists

Account #

Patient Name 

            It is entered as Last name, First Name, Middle Initial format

Patient Date of Birth 

           It is entered in the MM/DD/YYYY or MMDDYYYY as per the Billing

Sex

Modifiers | PreAuthorization / Prior Authorization

A modifier indicates that a procedure was altered but its not changed its definition.


Modifiers may be used as follows:

A service or procedure has both a professional and technical component

A service or procedure was performed by more than one physician

A service or procedure has been increased or reduced

Only part of a service was performed

An additional service was performed

A bilateral procedure was performed more than once

              Unusual events occurred 


Modifier 21 - Prolonged Evaluation and Management Services (Deleted, please use CPT 99354- 99357) 

Modifier 22 -  Unusual Procedural Services

Workflow process in Medical Billing

The following details provides the workflow of Medical billing process.

1.  The doctor sees the patient. After seen the patient, Dr front office person send the all information pertaining to the patient which includes Patient Demographics (Face sheet), super bills/charge sheets, insurance verification data and a copy of the insurance card to Indian Billing office via FTP/fax .

2.   In Billing office, Scanning department retrieves the files and prints them and ties up with the control log for number of files and pages. 

4.   Illegible /missing documents are identified and a mail is sent to the Billing office for rescanning.

6.Coding and pre-coding of the super bill/charge sheet and demographics for insurance, doctors, modifiers, CPT and diagnosis are done wherever required.

7. The claims data entry operator creates a charge, according to the billing rules pertaining to the specific carriers and locations .All charges are accomplished within the agreed turnaround time with the client.

8. Charges are verified by audit department for accuracy and compliance with rules.

9. Claims are filed and information sent to the Transmission department.

10. Transmission department prepares a list of claims that go out on paper and through the electronic media. Once claims are transmitted electronically, confirmation reports are obtained from clearing house and filed after verification. Paper claims are printed and attachments done if required and put into envelopes and sent to the US for postage and mailing.

11. Clearing house transmission rejections/errors are analyzed and take corrective action and again transmit the claims to clearing house

12. Once recieve the EOB( Expalnation of Benefits-Payments),  Cash applied team receives the cash files and post the payment in the respective accounts. This would helps to reconcile the deposits at the end of each month. while psoting the EOBS, Overpayments are immediately identified and sene the information to Dr office to refund the amount into the respective insurances. 

13. All rejected/denied claims,  research the reason for denial with remark codes in the EOB’s or Explanation of Benefits received and take appropriate action to resolving the issue. 

14. AR analysts are the key to any group. They record the processing time of each insurance companies and identify all claims falling above the processing time. Then the claims are researched for completeness and accuracy and insurance carriers are called if required. AR analysts are responsible for the cash collection and resolving all problems to enable the account to have clean AR. 

15. Insurance Calling team, calls to the insurance companies to identify the  reasons for non-payment of the claims.Calling details are passed on to the AR Analysts for resolution. Calling team works during the American Time zones.

16. Patient calling team calls up the patients to confirm receipt of bill and when they are going to pay. Based on client’s approvals budget plans and discounts for immediate payments are also undertaken.

A Note on Methodology

The size of a billing organization can range from a few staff to hundreds of employees, with employees added as the number of claims processed grows. 

Cost factors include the number of claims, average number of pages per claim, average processing time per claim, average payroll costs, and the percentage of claims that must be processed in paper or hardcopy format, including those received electronically but printed for compilation. All of these variables and more have been taken into account in our study. 

Savings percentages are derived from Laserfiche’s 20-year history and experience with over 25,000 installations worldwide. In this white paper, we present results for the following types of organizations as represented by our customers:

•Single-facility billing departments: 75,000 claims processed annually.
•Multi-facility billing departments: 225,000 claims processed annually.
•Third-party billing organizations: 750,000+ claims processed annually.

An ROI calculator is available upon request. With this tool, you can plug in your own variables and calculate the savings your organization will realize by implementing digital document management technology.

A number of steps are required to generate and file a medical claim from a patient encounter, including documentation compilation, quality control, financial verification, coding, billing input and claim processing. 

Often, these steps involve one or more staff members, and this simple list belies the complexity and effort involved in each of these steps. The work processes involved in generating and filing a claim can be dramatically streamlined with document management. These benefits are further enhanced by implementing an electronic document workflow process to automatically guide the file through the required stages.

Claim Processing Efficiencies

Source documentation can vary from a single encounter form to a multi-page file of supporting records. Portions arrive at different times and in a variety of formats that include paper, electronic documents and electronic data files. 

And documents may be received in a variety of ways, including physical delivery, fax, e-mail, CDs and FTP site uploads. In fact, without a digital document management system, the most effective way to compile and review the disparate documentation is often to print everything received electronically, which wastes time and resources.


Providers that have implemented an EMR/EHR application can send an electronic data file, which in effect transfers the printing and paper costs to the billing organization. The mail room becomes the initial record assembly area, where documentation is sorted into patient batches and folders are created and labeled. 

Documents are then routed to the first step or staff in the workflow process, which is typically quality control. Too often, duplicate files are received, which doesn’t just double the cost of compilation, but also requires staff to identify them as duplicates and then delete them. 

Defining Workflow

Workflow, a term that originated in the mid-eighties, has many definitions. For this study, we define workflow as a computer-assisted (or automated) organizational process. An organizational process is a collection of activities related to a specific commitment, adding value to a product or service of the organization. 

Workflow is often used synonymously with reengineering, but workflow automation and business process reengineering are not the same thing. Workflow automation is a software technology that provides a means of automating a business process. Reengineering is the act of analyzing the business processes of a company or practice and changing them with the goal of improvement. 

Thus, business organizations can automate business processes using workflow software without reengineering them. Likewise, businesses can reengineer business processes without work- flow automation.

Workflow is also not the same as workflow automation.

Any application that can route a document so that it flows (like e-mail) from one user to another can claim to be workflow. True workflow automation includes an array of essential features that go far beyond the simple routing of documents and depends on two critical factors, (1) automating manual process steps and (2) distributing information to the workgroup, in this case, to the physician and his or her staff. 

An automated workflow system has the following characteristics:

• Tasks These are activities that must be completed to achieve a business goal. The CPR (computer-based patient record) and workflow system in this study are task-based.

• People Tasks are performed in a specific order by specific people (i.e., nurses, physicians) based on business roles.

• Roles Roles are defined independent of the people or the processes that fill them; for example, the CPR defines a nurse’s role as different from a physician’s role in the physician’s office.

• Processes Processes are the sequences of steps to be performed based on business conditions. Workflow automation may mirror existing processes or call for redesigning processes to eliminate redundancies and bottlenecks and to account for simultaneity. 

Since redesigning processes involves an examination of why people do what they do and often requires changing the way people do their work, it may foster fear, uncertainty, politics, and resistance to change.

• Practices Practices are what actually happen in organizations. Only by capturing the practices is it possible to truly automate businesses.

• Policies Policies are formal written statements of how certain processes are handled. In most physician practices, policies are unwritten and must be remembered by the person assigned to the task.