...Lisa Collins Instructor: Mrs. Donna Purvis, MBA HLTH245 Principles of Reimbursement Management September 29, 2015 Ten Step Billing Process The ten steps of the medical billing process have been divided into three categories: The visit, the claim and the post claim. Following the billing steps to complete correct claims ensures that providers are paid accurately and timely for services and procedures. The Billing process begins with the preregistration of patients. Collecting personal, basic demographic information, and insurance information and entering that information into the database. All of this personal information can be referred to at any time during the medical billing process. Keeping up to date patient and insurance information makes patient check in more efficient and eliminated potential billing errors. Confirming financial responsibility is the next step in the billing process. Once a patient’s information has been updated in the computer system it is then the medical staffs’ responsibility to determine who will be paying for the services rendered for the appointment. Insurance providers are contacted and benefits are verified as different plans have different levels of coverage. Once the medical staff is aware of what the allowable insurance benefits are, contact with the patient should be made so the patient is aware of their responsibility for out of pocket, non-covered expenses, co-payments, and deductibles. During the appointment, the physician...
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...Correct Medical Billing and Coding in the Healthcare Industry Medical billing and coding is one of today's topics. When services are billed for patients, they must be coded based on the documentation the physician has dictated in the patients chart to receive payment from the insurance company. As the physicians office and/or hospitals practice correct medical billing and coding, this will prevent audits being brought forth in their practice and/or hospital. Kenny, Christopher,Correct Coding for Dialysis Billing Providers must ensure proper coding to avoid returned claim, 2012. This article is geared for those in the medical field who do coding and billing in hospitals for dialysis. The author is educating the coders and billers how to correctly code for dialysis billing. He mentions that The Centers for Medicare and Medicaid, issued a transmittal that has revised the Medicare claims processing manual as it pertains to hospitals billing for dialysis procedures that are non covered under the ESRD benefit for emergency dialysis. In addition, the author discusses how the hospitals should utilize Healthcare Common Procedure Coding System billing code G0275 and code 90935 for hemodialysis. Only to bill G0275, if the hospital is a ESRD facility, emergency services, and when dialysis is performed with related procedures, such as a vascular access procedures or when performed following treatment for an unrelated medical emergency. The author also continues to...
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...Summary The U.S. Government has emphasized EMR (electronic medical records) and ECS (electronic claims system) as an answer to reducing the costs attached to patient care. In addition, electronic systems help in expediting reimbursement of insurance claims. Yet, it is still difficult to perform this task. Currently more than 60 percent of all medical claims in the U.S. are mailed. Submission of paper claims dates back in the U.S. to the early 1950’s. One of the primary reasons for not implementing a new system is the cost of new EMR and ECS systems. In 1990, the federal government mandated that physicians start submitting their claims electronically. This standard only applies to large practitioners and “small” providers can request a waiver from submitting claims electronically. This waiver was established when the government recognized the financial burden new electronic systems could have on small providers. Small providers, however, are losing money due to the inability to access current technology. Mount Brighton is an affordable medical management company that can perform the electronic claims processing for both small and big providers. Mount Brighton is efficient and effective at maximizing reimbursement, working through denials, and working through the appeals process. Industry Analysis Our company will operate in the business-to-business sector providing medical and business solutions to medical and dental offices. In addition, our company...
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...2013 CODER INTERVIEW Like a regular business entity, healthcare facilities need continuous inflow of funds to continue existing. However, billing complexity in the health care industry is unlike all other industries. The biggest difference of healthcare from other businesses is the source of payment for services rendered: the majority of which is from a third party with pre-determined rates and strict prerequisites. Foundational to these prerequisites is the accuracy of medical coding. An interview with a coder provided fresh understanding of the coding profession. And a look into the private and government payers and insurers’ roles brings better understanding of their impact on reimbursement. MEDICAL CODING Medical Coding is the process of using standard codes in identifying medical services and procedure. This is used for billing and reimbursement from payers for services rendered. Medical code is foundational and standardized with industry-wide language. The use of the Healthcare Common Procedure Coding System (HCPCS) is mandated by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), (Medial Billing and Coding). THE INTERVIEW I interviewed an outpatient coder of Pennsylvania Hospital. Her job includes coding for hospital out-patients and Physicians’ in-patients and out-patients. She explained medical coding is quite complex and a coder needs proper schooling and training. She is a graduate of Health Information Management, a bachelor degree...
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...Fair reimbursement for healthcare professionals is a controversial topic. Is the clinician’s degree or the type of care provided and overall clinician’s performance that should be rewarded? In actuality, most private insurance carriers pay standard fees for service. However, Medicare is the exception because it limits the reimbursement of services provided by physician assistants (PAs) to only 85% (Wilkens, 2012). Undoubtedly, productivity and economic reimbursement are integral components of the healthcare system. Therefore, it is crucial to understand the various aspects that have shaped the reimbursement for PA services, including the Balanced Budget Act (BBA) of 1997, current reimbursement terms, and the national provider identifier (NPI)....
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...IN THE United States, primary care remains a medical model. This is in contrast to much of the world, where the 1978 Declaration of Alma-At a which recognized that attaining health for all also requires interaction from social and economic sectors - is considered standard. Today, there is much buzz about patient-centered medical homes, a concept that promises to transform the practice of American medicine. There is much to praise about this most recent iteration of the medical home. But the missing ingrethent in all these definitions and models remains public health. A population focus that addresses the social determinants of health is an essential component of primary health care. In the United States, such a comprehensive approach has been labeled community-oriented primary care. This model is built firmly on the Alma-Ata principles and incorporates a public health approach to health services. Community-oriented primary care organizes the delivery of health services, around a population, not simply a collection of individuals. It identifies a population - most frequently a geographically defined community - and uses epidemiology and interventions to improve community and individual health and well-being. In this model, both individual patients and the community are the foci of the delivery of health services. Primary health care stands at the intersection of personal and population health services. It requires integrating medical models of primary care that are centered on...
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...information or procedure information for clinical information; The coding system assist with reimbursement of services provided by facilities. • The most important aspect of ICD-9 coding system is it defines disease in category allowing medical personnel to determine diagnosis, disorders, and procedures incorporating patient data and can assist in utilization process. CPT- Current Procedural Terminology- CPT is another coding system to document medical services, surgical procedures, and diagnostic procedures. CPT codes are HCPC codes that can identify what has been done to a patient to assist in the diagnosis and prognosis of the patient by physicians, billers, coders, and administrative personnel. • The importance of CPT codes is it is a uniformed coding system for medical personnel to document accurately and maintain records for billing and diagnostic purposes. CMS- Centers for Medicare and Medicaid Services- An agency within the Department of Health and Human Services that administers the Medicare and Medicaid program and standards for HIPPA. • The importance of CMS is it provides the different standards that Medicare and Medicaid providers must adhere to. CMS-1500- Health Insurance Claim Form- Health insurance claim form physicians and facilities use to process procedures and services rendered to patients. • The importance of CMS-1500 is that medical providers are able to document what was done to patient for diagnostic purposes and accurately...
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...Ambulatory Medical Records are medical records in which physicians use. If the physician is using the same information system as the hospital, they can be linked together to show visits in the ambulatory setting. The medical records are kept at the office that provides the care (Wager, Lee, & Glaser, 2009). The AMR system includes billing, coding, and the transcription of doctor’s notes. AMR’s are important because they can ensure compliance, increase the time which doctor’s spend with their patients, and reduce the space in the offices for paper charts. * CMR- Computerized Medical Records are health information about patients stored within the system. Recently, the use of computerized medical records has become a requirement for the government and CMS in order to obtain reimbursements for services rendered (Wager, Lee, & Glaser, 2009). CMR’s are important and increases reimbursement time processes, increases retrieval times of patient records, makes physician handwriting more legible, and assists with organization of patient information. The CMR includes information that was previously obtained by scanning the patient chart into the computer system. * CMS- Centers for Medicare and Medicaid focuses on physicians, nursing homes, long-term care, home care and hospitals. They ensure compliance of government policies and procedures of these facilities. CMS aggregates data from CMS1500 (Insurance claims forms) for analyzing national health care reimbursements as well...
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...Medical Billing and Coding The program that I am currently in, is medical billing and coding. Some professionals that are medical coders with a minimum of an associates degree, are a part of an organization that is called AAPC. AAPC stands for American Academy of Professional Coders. In 1988, AAPC was founded to provide education and professional certification to physician-based medical coders (AAPC, 2014). In order to be a part of this organization, a member has to follow by a specific protocol. Another organization that is most known and recognized, is The American Medical Billing Association (AMBA).There's a list of different certifications that one could gain, as a medical billing and coder. Just to name a few more, CMRS (certified medical reimbursement specialist) specializes in insurance reimbursement. CHBME (certified healthcare billing and management executive) is geared toward managers, executives, and supervisors (A-T-M-B, 2014). Professional standards in the healthcare field, means having a certification or a license. Having a certification, means you indeed, have met the specific requirements. Depending on the specific job one chooses when entering into the healthcare field, in order to practice in the state that one lives in, it is mandatory that one has a license to practice within that state. The importance of professional standards in healthcare, is for one, to distinguish yourself from others who are not certified or licensed. It shows how dedicated you are...
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...| Billing Process LaJessica Demas July 26, 2015 Christine Singel The medical billing process makes sure that all parties in the health care facility such as doctors, patient care techs, nurses and insurance company are paid and credited properly. The process makes sure that they all get paid, either by the insurance company or by the patient. Everyone involved must fulfill important responsibilities in order for everyone to get paid. Patients that are receiving any type of healthcare services are billed for the services they receive inside of a hospital or clinic. If the patient has any type of medical insurance, then the way they are billed will depend on the type of insurance coverage that they carry. The first step of the billing process involves determining the patient's insurance coverage and billing insurance for the patient's healthcare services. This is done during admissions or a visit, a medical assistant will collect a patient’s information such as, the patient identification card, insurance name, policy number and deductible amount. Next, the insurance provider will be contacted through phone or a computer based system, to confirm that the patient is covered, then collect any co-pay if needed. Billing third party plans, is the insurance claims or employee benefit plans for separate entity. Billing a third party plan can be a patient’s employer, which may choose to help finance a patient’s health care cost. These components...
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...Paul Carter HCA-240 Health Care Accounting and Billing April 6, 2013 Professor York Billing Process What is the process that is utilized when producing a final bill? In which ways are pricing and charging different in health care from other industries? What are the ways that private and government insurers and payers impact the actual reimbursement process in health care? The process for producing a final bill in health care starts with the medical record and coding which are communicated to the payer to start the payment process. In 1996 the Health Insurance Portability and Accounting Act (HIPAA) designated two specific coding systems to be used when reporting to both public and private payers. The two coding are International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) and Healthcare Common Procedure Coding System (HCPCS). The ICD-9-CM provides information for diagnoses and procedures while the HCPCS just provides information in the procedure area. The next process would be the charge entry and charge master which have to do with the capture of charges for the services performed, incorrect billing and billing late charges. With charge capture can be done in two different ways paper documents or charge slips. Which is done by the data processing or the business office that identifies the services that was performed on a patient? When producing a final bill they will also sometime use the charge explosion system that will use one code...
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...EMR and Health Care Fraud The realization of the Electronic Medical Record (EMR) is one of the greatest technological health care achievements. However, this realization has brought about many additional concerns. Regarding EMR, some of these concerns include: billing for services not provided, misrepresenting dates/locations/providers of services, incorrect reporting of diagnoses or procedures, double billing, and upcoding. (Piper, 2013) Many of these issues did not just appear with the introduction of EMR, but there was a surge of billing fraud complaints--from patients and Medicare recipients. EMR implementation has changed the modern health world, but it does not come without its setbacks. “The $1,000 Pap Smear” EMR has been called out for its easy set-up for...
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...Evaluating Compliance Strategies Patricia Estrada HCR/220 November 2012 Deborah Ryan Medical billing and compliance strategies are used to bill for medical procedures and treatments. The compliance strategies are in place to prevent incorrect billing, but mistakes are still made. Answers to the importance of correctly linking procedures and diagnoses, the implications of incorrect medical coding, and how medical coding, physicians and payer fees are related to the compliance process will be discussed. It is very important that procedures and diagnosis are correctly linked together. There are certain steps to follow that help to correctly link the procedure to the diagnoses. By following the correct procedures to apply the correct codes that link procedure with diagnosis, insurance companies can be correctly billed for reimbursements. Correctly connected claims can be analyzed and to make sure charges are for medically necessary services provided to the patient. Correct claims help reduce the chance of an investigation of the practice of fraud and the risk of liability in an investigation does occur. (Valerius, J., Bayes, N., Newby, C., & Seggern, J. , 2008). If the procedures are not linked correctly to the diagnoses, then they will not be covered by the insurance company and therefor will not be paid. The major implication of incorrect medical coding would be fraud. Even though incorrect work may simply be an error, it may also represent a deliberate attempt...
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...systems are required to perform tasks like billing, scheduling, and receive payments from payers. Each system has a purpose and function that fulfills the needs of the organization to operate. The systems are used for administrative, statistical, and financial reasons. Organizations need to have the right system to perform the needed tasks correctly and efficiently. Ambulatory Medical Record Ambulatory medical records (AMR) are medical records from an urgent care or physician offices. If the urgent care or physician’s office is using the same systems as a hospital they can be linked to show visits in the ambulatory setting. The ambulatory medical record also can be from home care facilities that make visits to the patient’s home. The medical records are stored within the office providing the care. The ambulatory medical records system can be designed to include billing, coding, and transcription of physician notes. The benefits of the AMR are physicians can also increase compliance to standard and guidelines of diseases, increase time spent with the patient, and reduce space needed in offices for paper charts. Computerized Medical Record A computerized medical record (CMR) is the health information and data about an individual stored within a computer. The use of computerized medical records recently has been a requirement from the government and the CMS to receive payment for services rendered. The use of computerized medical records has advantages like faster retrieval...
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...Home Based-Medical Billing - Marketing Plan Outline 2.0 Situation Analysis Medical billing / Coding is one of the fastest growing health care jobs, The US Bureau of Labor Statistics predicts that medical coding and billing will remain among the top fastest growing occupations for many years to come. Fact is: over 500,000 practicing physicians and hospitals in the USA rely heavily on medical coders and billers for customer service, and more importantly: to get reimbursed for medical services provided to patients. (http://www.medicalcodingandbilling.com) Many Billing services currently operate to manage medical practice billing among other services offered, providing physicians with the benefit and convenience of outsourcing their billing duties to third parties in order to relieve medical professionals of the tedious and challenging work that entails medical billing and account collections. National statistics show that only about 70 percent of insurance claims, initially submitted on paper, are ever paid by insurance carriers. With the advancements of health information Systems and the increase requirement and demand for electronic submissions Claims have increased the reimbursement percentage tremendously. A survey by the American Hospital Association concluded that about 18% of medical billing and coding positions remain unfilled due to a lack of qualified candidates. Occupational trends and future outlook for Medical Billing and Coding Specialists remain at the...
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