Medical Billing & Coding is the process of translating information from patient records, treatments, tests, procedures, and diagnoses into the standardized codes used to bill patients and third-party payers such as private companies or government-owned agencies (Medicare/Medicaid).
The ICD-10 & CPT codes are extracted from clinical data charts and physician’s notes. Coding must be in compliance with the patient’s encounter with the physician. Must be as specific as possible in regards to capturing reimbursement for rendered services.
Medical billing software & technology
helps in streamlining processes as it includes claim creation, filing & scrubbing, integrated clearinghouse, and denial management tools.
The software helps Medical billers & coders to process the patient treatment information into numerical codes ICD-10 codes and CPT codes which describe the medical services rendered for claim filing & reimbursement.
To avoid revenue leakage we need to address 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 Professional Tasks is to process Encounter Form/Superbills/Charge tickets containing patient data including treatment records. Insurance information, and upfront payments. Verify patient coverage submit claims and follow 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 in 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 Coverage) to establish financial responsibility except in a medical emergency when care is provided immediately and insurance is checked after the encounter.
The medical insurance specialist also examines the patient information form and insurance card to see whether other coverage is in effect if the patient has multiple health plans.
We need to determine which Primary insurance, Secondary insurance, and Tertiary insurance, a third payer, is possible. Supplemental insurance, a “fill-the-gap” insurance plan that covers parts of expenses, such as coinsurance, mostly pays under the primary insurance plan.
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 reimbursement responsibility and the scope to which the other plans will contribute when an individual is covered by more than one plan).
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 functions 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 clearinghouses for submitting claims. and charge the providers for each claim submitted electronically and charge for sending a paper claim to a certain payer. Clearinghouses 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 connection. that meets the exact standards set by HIPAA.
The claim is either accepted or rejected, but either way, a status message is then updated in your account. It then alerts you (e.g. by email) that you have accepted or rejected the claim. If rejected, corrected claims are re-submitted to the insurance payer.
Once the claims are processed you’ll receive a reimbursement check along with an explanation of benefits (EOB).
Payment Posting is one of the most vital steps 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 claims and payers’ returns on the explanation of benefits reports.
You can enter the allowed amount, paid amount, and patient responsibility information. After the claim is processed we get the detail of benefits either on a paper file i.e. EOB or electronically on an ERA file.
The most important task for the Medical billing team is to get faster reimbursements to Optimize the Payment Cycle. The 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 to follow up on accounts Aging 20 Days with insurance companies (Via web portals, fax, IVR & Calls) to ensure timely payments & quick settlement of Aged & unpaid claims.
The Medical billing team should Follow-Up on claims in which absolutely no status is known for the claim. And the claims 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 also every effort is made to resolve the denial.
To increase the client’s returns and decrease the medical office outlays.
Those claims 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, Generally including In-Network deductibles and non-covered benefits as per the insurance plan/policy.
Claim Creation is one of the key areas of the Revenue Cycle. At PhysicianRCM, we have excellent skills in handling Charge Entry & Claims Submission on various billing software for multiple specialties.
We believe that precise eligibility verification directly impacts the reimbursements, minimizes the Denials / Rejections, help to submit clean claims & increases upfront collections. Our team of professionals tracks every unpaid claim to fix denials & get faster reimbursements.
We believe that minimizing denials boosts your Practice’s profitability & Cashflow. We work with all EHR / PM systems and the primary motive. It follows strict quality standards which cut the room for errors that may lead to Denials. We have sound experience in handling various medical billing software.