treatment information into numerical codes ICD-10 codes and CPT codes which describes the medical services rendered for claim filing & reimbursement. To avoid revenue leakage we need to address the common billing errors like  nonspecific coding; missing information; timely filling; incorrect patient identifiers; duplicate claims; up-coding & unbundling; and not supporting medical necessity.

Medical Billing & Coding Services Professionals

Medical Billing & Coding Professionals Tasks is to process Encounter Form/Super bills/Charge tickets contain patient data including treatment records, insurance information, and upfront payments. To verify patient coverage, submitting claims and following up on claims with health insurance companies in order to receive payment for services rendered.

Insurance payers offer different levels of coverage to their subscribers, and as the medical biller you must be able to understand payer contracts to follow-up on claims. As payers or networks have standardized contracts that they offer to healthcare providers.

The reason, patients check whether the provider is a participating / in-network provider to avoid paying higher charges PPOs and HMOs. Nonparticipating provider (Non-PAR) provider who does not join a particular healthcare plan. When the patient has out-of-network benefits, the payer’s rules concerning copayments/coinsurance and coverage are followed as it is common when the health plan is an HMO, the patient is responsible for the entire bill.

To be paid for services, medical practices need to establish financial responsibility and the medical biller must check Insurance Benefits, Preauthorization & Referral requirements, and Coordination of Benefits (Determine the primary payer if more than one insurance Coverages) to establish financial responsibility except in a medical emergency when care is provided immediately and insurance is checked after the encounter.

Medical Insurance Specialists

Medical Billing & Coding experts Or Health care billing services provider also examines the patient information form and insurance card to see whether other coverage is in effect, if patient has multiple health plans. We need to determine which is the Primary insurance, Secondary insurance and Tertiary insurance, a third payer, is possible. The supplemental insurance, a “fill-the-gap” insurance plan that covers parts of expenses, such as coinsurance, mostly pay under the primary insurance plan.

Coordination of Benefits

Deciding which payer is primary is also important because insurance policies contain a provision called Coordination of Benefits (COB). As per CMS, COB allows plans that provide health and/or prescription coverage for a person with Medicare to determine their respective payment responsibilities (i.e., determine which insurance plan has the primary imbursement responsibility and the scope to which the other plans will contribute when an individual is covered by more than one plan).

Information of the Patient

An Encounter (EC) Form – either electronic or paper –contains the billing information of the patient and the services provided by the physician, these forms (also called superbills, charge slips, or routing slips) list the Diagnoses (ICD) codes, procedure(s) (CPT) codes, Modifier code (if required), POS code, Date of service, rendering physician, Insurance Information, Prior-authorization # / Referrals #, Tests / Supplies, Follow Up etc.

Clearinghouse Scrubs

Clearing house that function as intermediaries to forward medical insurance claims to the payer and check the claim for errors and verify that it is compatible with the payer software system. The PM / HER Systems we use can have different clearinghouse for submitting claims and charge the providers for each claim submitted electronically and charge for sending a paper claim to a certain payer .Clearing houses may submit claims to the payers directly, or they could have to send a claim through other clearinghouses before reaching the payer(s).

The clearinghouse scrubs the claim, checking it for errors and once the claim is accepted, the clearinghouse securely transmits the electronic file to the specified insurance payer through a secure connections those meet the exact standards set by the HIPAA. The claim is either accepted or rejected, but either way, a status message is then updated in your account. It then alert’s you (e.g. by email) that you have an accepted or rejected claim. If rejected, corrected claims are re-submitted to the insurance payer. Once the claims is processed you’ll receive a reimbursement check along with an explanation of benefits (EOB).

Patient Control Number

Payment Posting is one of the most vital step in the RCM process & precise posting represents overall billing proficiency and sorts out reasons for low influxes, if any. We can post payments using unique encounter numbers, also known as Patient Control Numbers (PCN), which Billing Company submits on claims and payers return on explanation of benefits reports. You can enter the allowed amount, paid amount, and patient responsibility information. After the claim processed we get the detail of benefits either on paper file i.e., EOB or electronically on ERA file. The most important task for the medical billing & coding team is to get faster reimbursements to Optimize Payment Cycle. 

Accounts Receivable / Follow-Up process directly impacts the cash flow. The A/R Follow up begins as the claims are created and submitted (Electronic/ Paper claims)to Health Insurance payers. The A/R Follow up Team should start follow up on accounts Aging 20 Days with insurance companies (via web-portals, fax, IVR &Call)to ensure timely payments & quick settlement of Aged & unpaid claims.

Medical Billing and Coding Team

The Medical billing & coding team should Follow-Up on claims in which absolutely no status is known for the claim and the claims which remain unpaid for various reasons like, Authorization Issues, Referral Issues, Medical Necessity and Medical Records requests, Non-Participation with Insurance Network, Terminated Insurance, Coordination of benefits (COB), Incorrect Diagnosis / Procedure Codes, Inclusive Procedures, etc. Denied Insurance claims require extra effort for resolution. The corrected claims are sent to the Insurance Payers and every effort is made to resolve the denial to increase the client’s returns and decrease the medical office outlays. Those claims which cannot be further worked upon and the final bill is sent to the patient (statement with a clear explanation for the balance due) for payment, it generally includes In-Network deductibles and non-covered benefits as per the insurance plan/policy.

Why you Should Choose Physician RCM for Medical Billing and Coding Services

Claim Creation is one of the key area of Revenue Cycle. At Physician RCM, we have an excellent skills in handling the Charge Entry & Claims Submission on various billing software for multiple specialties. We believe that the precise eligibility verification directly impacts the reimbursements, minimize the Denials / Rejections, help to submit clean claims & to increase upfront collections. Our team of professionals track every unpaid claim to fix denials & get faster reimbursements. We believe that minimizing denials boost your Practice profitability & Cash flow. We work with all EHR / PM systems and the primary motive is to follow strict quality standards which cuts the room for errors that may lead to Denials. We have a sound experience in handling various medical billing software.