Physical therapy services

The Real World of Outpatient Claims

by Nitin Chhoda PT, DPT | Oct 24, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Medical insurance billers (MIBs) learn a wide variety of skills and obtain a diverse array of knowledge in preparation for a career as a biller. Conditions and protocols in the work environment can vary significantly from the educational arena, depending on the facility’s policies. In this informative article, Nitin Chhoda takes a look at the real world of outpatient claims.

New Beginnings

An appointment for a new patient begins with a comprehensive health form to collect as much information as possible about the reason for the visit, along with health concerns, conditions and ailments.

The outpatient claims process include obtaining a copy of the individual’s photo ID and insurance card to verify eligibility and that the policy is valid. Healthcare identity theft is an increasing problem and MIBs must be vigilant.

As part of the registration of the outpatient claims process, MIBs review the guidelines and specifics of the patient’s policy. Exclusions, limitations and prerequisites may apply that can affect available treatment options and the timely collection of the provider’s revenues.

Co-pays and Deductibles

Patients are typically required to pay a portion of their healthcare costs through co-pays and most policies have a deductible that must be met. Part of the outpatient claims process includes collecting the required co-pay, preferably before the patient sees the provider. Insurance data is presented to the practitioner, enabling him/her to render care that meets with the carrier’s policy specifications.

Just the Facts

In the world of outpatient claims, the facts encompass the provider’s diagnosis and statement of services provided. MIBs assemble all the necessary data and documentation, assigning numerical and alphabetical codes that will be used for reimbursement purposes when the claim is transmitted to the clearinghouse.

Follow Up Visits

Continuing care isn’t just for patients. MIBs monitor and track claims, outpatient claims included, to ensure they reached their destination and determine the payment status. If a problem arises, billers will need to conduct a follow up and revisit the claim to rectify any errors or obtain payment.

MIBs are also responsible for contacting patients for unpaid balances on their accounts. When patients have difficulty paying their bill, MIBs may be authorized to negotiate payment plans or turn the account over to a collection agency.

In the real world of outpatient claims, the expertise of the certified medical insurance biller is a key element in the financial success of a practice.

Medical billing people are the keepers of the data and outpatient claims procedures that facilitate the flow of revenues to practitioners, forging the essential monetary links between patients, practitioners and payers.

Bundled Medicare Payments with Obamacare?

by Nitin Chhoda PT, DPT | Oct 22, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Bundled payments for Medicare patients is one of the big changes that comes with the Affordable Health Care Act, also known as Obamacare. The loss of revenue will be obvious for practitioners.

Obamacare places restraints on payments made for Medicare patients, cutting them by up to 20 percent, and bundles payments for treatments and procedures that were billed separately in the past.

Bundling For Savings

Approximately one-fifth of the funding for Obamacare comes from slashes to Medicare reimbursements to medical providers.

Obamacare removes the traditional fee-for-service payment model, replacing it with a bundled system for inpatient hospital services and post-discharge treatment, also known as episode-based payment.

The new system’s intended goal is to reduce the length of hospital stays and readmissions. When an individual is hospitalized, they will be treated by a team of healthcare professionals for a specific length of time.

The team can include medical professionals from multiple care facilities. The grand experiment in healthcare delivery to patients began in Jan 2013 and will operate for three years.

The members of a treatment team will be rewarded with financial incentives for getting Medicare patients cured/recovered quickly.

Unfortunately, the system opens the door to the potential of reduced quality of care and a temptation to cut corners.

Payments are fixed at a set amount. The fewer resources used on patients, the more money goes to the hospital.

Hospital At Home

As part of the Medicare imperative to cut costs, the Independence at Home initiative began in Jan. 2012. The program evaluates the profitability and outcomes of home monitoring technology to discover if costs are reduced and care improved.

The Medicare-related programs are based on a 2008 essay by President Obama’s healthcare advisor, Dr. Ezekiel Emanuel.

The doctor postulates that the rise in healthcare costs can be traced to patients who “overuse” the healthcare system. He advocates for the removal of “fluffy, self-indulgent excess” out of the system and giving doctors financial incentives to deliver less care to patients. Emanuel’s views may come to fruition with the Independent Payment Advisory Board (IPAB).

The IPAB Ingredient

Obamacare established the IPAB, whose sole function is to find more ways to reduce healthcare spending, specifically in the Medicare arena. The 15-member panel isn’t elected and can’t be replaced by the will of the people.

IPAD could mean radical cuts in the future for Medicare patients.

The panel will be responsible for evaluating available treatment options and deciding which treatments and procedures provide the best value for the money spent.

Their recommendations automatically become law unless Congress counteracts them with a three-fifths super majority vote. IPAB’s recommendations start in 2015 and will be implemented in 2018.

There’s no guarantee that bundling payments for care delivered to Medicare patients will improve quality of care or reduce costs.

To retain more of the fixed fees allotted for hospital care, Medicare patients could lose access to tests, treatments and medications that are considered too costly, while IPAB recommendations will hold more such cuts in the future.

Reimbursement Claims: How Can to Make Sure I Get It the First Time Around?

by Nitin Chhoda PT, DPT | Oct 21, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Clean reimbursement claims are the bread and butter of the medical billing industry. They pass the scrubbing process at clearinghouses quickly and generate revenues faster. Billers can take a variety of precautions to avoid denied claims and in this telling article, Nitin Chhoda reveals the most common billing mistakes.

The first rule of medical billing is never assume anything. If a medical insurance biller (MIB) has any doubt due to a practitioner’s illegible scrawls, the type of treatment received or procedure performed, it’s imperative to contact the clinician for clarification.

Coding Errors

Mistakes and oversights in coding represent the number one reason that reimbursement claims are denied. Electronic medical record (EMR) technology can identify potential claim problems and notify the user. Insurance carriers are constantly seeking ways to avoid paying reimbursement claims and examine coding closely for the following items:

Mismatched coding that creates inconsistencies in the claims. A good example is gender specific ailments.
Truncated coding doesn’t address all three levels of the practitioner’s diagnosis is suspect.
Up and down coding is a red flag for carriers. Trying to obtain higher reimbursement claims or coding at a lower level in an effort to avoid denials can result in penalties, or the carrier may decide not to do business with the clinician.

Document Everything

Clean claims provide the appropriate documentation for every item, from the patient’s identity to the treatment provided. MIBs must ensure that reimbursement claims contain complete and accurate information on all facets of the patient’s visit.

When claims are returned with a request for supporting data, insurance carriers can become suspicious and suspect the medical provider or the MIB of altering or recreating documents to support a claim.

Billing Blunders

Unbundling is the act of billing separately for elements that should have been claimed as a whole. Insurance carriers allow for unbundling under very specific circumstances, but MIBs should utilize caution when doing so. Coding is designed to cover an entire treatment or procedure and will single out a claim for closer inspection.

Complying with Carriers

There’s no standard procedure when dealing with insurance carriers. Each company establishes its own rules for reimbursement claims submissions. MIBs who don’t adhere to the carrier’s specifications will be deemed non-compliant and the reimbursement claims will be denied. That can also encompass failure to obtain a pre-approval prior to the patient’s treatment.

Clerical Oversights

Correct coding and detailed documentation won’t avoid a denial if the reimbursement claims contain omissions, data entered in the wrong location or typographical errors.

Even simple items, such as misaligned paper in a printer, can pose sufficient reason for a clearinghouse to reject a claim.

Most mistakes can be identified and corrected prior to transmission to the clearinghouse. It takes only moments to double check a claim before it’s sent, but correcting and resubmitting reimbursement claims can take hours of work and severely disrupts the flow of revenue. Knowing where the most common errors occur is the first step toward filing clean claims.

Claims: Stepping into the 21st Century with Computerization

by Nitin Chhoda PT, DPT | Oct 18, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Software

Computerization is no longer a luxury for a medical insurance biller (MIB). It’s a necessity that enables billers to handle hundreds of reimbursement claims each week and keep revenues flowing to their clients’ accounts.

In this insightful article, Nitin Chhoda outlines the benefits of electronic medical record (EMR) technology for the 21^st century billing business.

Simply put, computerization is the process of electronic recording, storing and retrieving of data.

Billing software and integrated EMR systems are available and both offer electronic medical billing and claims management abilities.

The primary difference is that billing software can cost hundreds and even thousands of dollars, while EMR systems can be obtained from reputable vendors for free.

Meeting Mandates

Computerization is necessary under the Affordable Health Care Act to participate in government operated health insurance programs and submit claims to commercial insurance carrier clearinghouses.

EMR systems also provide the mandated security safeguards required by HIPAA for the transmittal of patient information.

Ninety-eight percent of government claims are reimbursed within 30 days with EMR technology and reduces the turnaround time with commercial insurance carriers to as little as 10 days. EMRs encompass a variety of measures to ensure security for authorized personnel, from passwords and time stamps to biometric recognition protocols. Payments can be posted and patient accounts monitored for amounts owed.

Paperless Documentation

Computerization allows MIBs to assemble a complete record of a patient’s diagnosis, treatment and procedures without the use of paper records. Documentation is gathered for every step of the patient encounter and the data is stored electronically where can be accessed whenever needed.

Information data, including claims, can be stored on the computer or in the cloud, and paper reports can be printed when necessary.

An EMR allows users to import written forms and documents into the software program for storage. The software can be utilized with desktop computers, laptops and tablet technology. MIBs can work from any location where a high-speed Internet connection is available, providing billers with the freedom to work from virtually any venue.

No More Excuses

Insurance companies can no longer claim they didn’t receive the necessary documents in an effort to delay payments. Clearinghouse computers automatically send billers notification when claims are received. Billers can use their EMR to track, monitor and manage claims throughout every step of the payment process.

Customization and Coding

Custom documents can be created within EMRs to satisfy the individual requirements of each insurance carrier.

Claims reimbursements depend on the proper coding and EMRs are able to handle the transition to updated ICD-10 codes with ease.

EMR technology facilitates the claims process for billers and meets all the requirements for the secure transmittal of patient information.

The technology provides a full level of computerization for every task a biller undertakes. The software systems eliminate paper records and offers portability, enabling billers to expand their repertoire of claims services and open up on-the-go opportunities.

Medical Insurance Billers: How to be Better in Business

by Nitin Chhoda PT, DPT | Oct 12, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Every entrepreneur dreams of launching a successful business, but many are at a loss once the goal has been achieved. Medical insurance billers (MIBs) may be tempted to rest on their laurels once they’ve made it to the “big leagues”. In this revealing article, Nitin Chhoda provides medical insurance billers with helpful advice when they’ve outgrown their home-based business.

It’s easy to let day-to-day operations slide a little in the excitement and chaos of moving to an outside office.

Joining the ranks of highly visible businesses means medical insurance billers will need to work twice as hard and employ every tool at their disposal to attract and retain new clients.

Location Isn’t Everything, But It Helps

It’s tempting to rent office space in a highly visible venue, but it may not be the best solution for the budget. Discount pricing doesn’t necessarily mean a low-rent district. It’s possible to strike an equitable deal for space in under-utilized structures.

Many business owners are choosing to rent a home to house their enterprise. It can offer a cost effective solution that provides a user friendlier atmosphere. Medical insurance billers that take this route should check local laws and ordinances to confirm they can legally conduct business from the location before committing to a specific property.

Appearance Counts

The face a business displays to the public has a significant impact on clientele. Potential clients that see a structured and organized office will perceive the business as professional and the medical insurance billers as someone who are efficient and get results.

Accommodate the Customer

Business expansion dictates that the MIB assume new clients and that may necessitate moving out of their comfort zone to land new accounts. They may be asked to provide services not currently offered. Medical insurance billers should always be willing to learn new things and do whatever is necessary to accommodate clients.

Medical insurance billers should endeavor to provide the customer with what they want, as long as they have the appropriate professional skills and knowledge to do so.

Growth and Expansion

Medical insurance billers typically move out of their homes and into the public domain when their customer base will support it. Beware of rapid expansion and acquiring too many new clients. The result is an MIB that feels overwhelmed, with the inability to provide each client with the personal attention they deserve. An over-abundance of work entails hiring additional staff that may require significant training.

Be realistic when planning goals and anticipating revenues. Always expect the unexpected, from replacing equipment and hiring staff to unforeseen accidents. Medical insurance billers may need to increase their rates, but use caution or run the risk of losing even established clients. Think quality, not quantity.

The Little People

Being charming, gracious and accommodating is easy when physical therapy billing business owners are seeking their first clients.

The same rules apply when medical insurance billers are at the helm of a growing enterprise. No business owner should ever forget the individuals, clients and subsequent referrals that helped them reach their current level of success.

Insurance Lingo: Learning to Talk the Talk of the Medical Billing World

by Nitin Chhoda PT, DPT | Oct 9, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Medical insurance billing encompasses much more than entering numbers in a pre-made form. Medical insurance billers (MIBs) must have a strong working knowledge in a variety of fields and understand the many terms they’ll encounter.

Whether MIBs choose to work in a medical facility or launch a home-based business, they’ll find it extremely difficult to find employment or clients if they’re not familiar with the terms of the trade. Nitin Chhoda discusses more.

Medical Terms and Codes

CPT and ICD-10 codes are the method MIBs use to describe to insurance companies the diagnosis and treatment that each patient received.

Most healthcare providers only use a fraction of the thousands of available codes, but MIBs must be familiar with the lexicons used by their clients.

Billing software or electronic medical record (EMR) technology is an essential. It’s capable of handling all the coding needs and tasks MIBs will require.

Insurance Idioms

Insurance coverage is available as an individual policy (purchased by individuals) group (provided by employers) and government programs (Medicare, Medicaid, CHIP, CHAMPUS VA, TRICARE and Workers’ Compensation). Each will have its own set of rules dictating what type of services and procedures are covered. Terms to know include:

Beneficiary – who is eligible for services;
The insured – the primary person who has the policy, making it possible for his/her dependents to receive services;
Dependents – a spouse or children;
Co-pays and deductibles – costs paid by patients as individuals or as a family;
Provider – healthcare professionals, from those who treat clients to facilities that provide medical supplies;
Exclusions – services, procedures and treatments that are not covered;
Pre-existing condition – a medical condition that existed before the policy took effect;
Maximums – the maximum amount an insurance company will pay within a year or lifetime;
Pre-approval – services or treatments that must be approved by the payer prior to receiving them;
Co-insurance – a second policy that provides medical coverage and shares the cost of an individual’s costs.

Payers and Clearinghouses

Clearinghouses use EMR software to receive reimbursement claims and forward them on to insurance companies for payment. Insurance companies (payers) have a language all their own that’s employed when dealing with practitioners and medical billing professionals. Common terms include:

Usual fee – the cost doctors charge for specific services;
Customary fees – are based on 90 percent of fees charged within a geographic location;
Reasonable fees – is the lesser of what the doctor bills, usual fees, customary fees or a special fee that must be justified;
Provider network – is a network of medical providers and facilities that beneficiaries are allowed to see that are covered under their insurance policy.

Numerous educational and certification resources are offered by professional MIB organizations to assist individuals in learning the lingo of the medical insurance billing field. Individuals can find informative books at the library, subscribing to online MIB lists and forums and asking questions, and gain experience through mentoring.

An MIB who can talk the talk with providers and payers will find multiple avenues in which to demonstrate their acumen.