Physical Therapy Billing

Health Insurance and Its Top Three Mistakes or Issues

by Nitin Chhoda PT, DPT | Jun 23, 2019 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

There are three major mistakes within the office setting that are contributing to a loss of revenue through non-payment. The errors can easily be prevented and some can be eradicated before patients ever arrive for their appointments.

Clinics across the nation are feeling the effects of longer turnarounds on reimbursements and outright denials by health insurance companies to pay for services.

Verify Health Insurance Information Each Time Services Are Provided
The number one cause of denied reimbursement claims is a failure to verify health insurance information. Loss of employment and changes in insurance coverage can occur at any time. It’s essential that client coverage is verified for each patient anytime services are rendered.

Denials occur for any number of reasons, but the most common is the coverage has been terminated, followed by the patient being ineligible. Many health insurance plans require pre-authorization for procedures and have limits on benefits.

Failure to obtain permission or determine if the client has reached a maximum benefit amount will result in denial of payment. Practitioners should also ascertain if specific services are covered.

Current Patient Information Is Essential
They may seem like simple errors, but incomplete or incorrect patient information is the second most common cause of denials. Clinicians should ensure that the client’s name is spelled correctly and the date of birth is accurate, along with the address, complete contact information and gender.

Some patients have healthcare coverage through multiple providers, requiring clinics to perform additional checks to coordinate benefits. The policy holder and their relationship to the patient must be clear.

Each health insurance provider has its own set of rules for submitting claims and special attention should be paid to ensure those requirements are met.

Diagnosis, Procedure Codes and Sloppy Handwriting
Diagnosis and procedural codes provide essential information to health insurance companies about the patient’s condition, symptoms and treatment. Codes that don’t match the information provided can result in a denial on the grounds that the procedure wasn’t medically necessary or it doesn’t match an authorization.

Clinicians should ensure that their medical billing and coding experts are utilizing current codes and that they’re updated yearly. Another source of denials is poor penmanship on the part of the practitioner, a situation that is easily corrected with implementation of an integrated electronic medical record (EMR) system.

Navigating the labyrinth of rules, regulations and requirements set forth by health insurance providers can be a daunting process.

Human error and failing to verify health insurance information complicates the process, leading to payment denials and loss of revenues.

Vigilance is the only cure for clinics still using paper records. Implementation of an EMR transitions clinics away from wasteful paper records and virtually eliminates the top three mistakes of health insurance claim submissions that rob practitioners of revenues.

Medical Coder and Practice Staff’s Ethics are More Important than Their Typing Speed

by Nitin Chhoda PT, DPT | May 5, 2019 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

There’s a code of ethics that automatically comes into play in medical offices and employees are cognizant of this.

Staff and medical coder are aware that they can’t share personally identifiable information with outside sources, but what they don’t realize is that a casually made comment can also break the bonds of ethics and the law.

Medical billing and coding specialists deal with confidential information each day.

It’s important for them to perform their tasks with alacrity, but it’s imperative that their moral and ethical standards surpass their typing speed.

Practice owners want reimbursement claims filed as quickly as possible, but they can’t overlook or tolerate a breach of confidentiality no matter how efficient the medical coder is.

Practitioners have a myriad of state and federal agencies with which they must comply or they open themselves to lawsuits. A medical coder who gossips and shares patient information with anyone else is placing themselves at risk, along with the practice owner and the entire medical facility. Penalties can be leveled through civil, state and federal agencies.

Don’t run afoul of common, statutory, administrative and case law.

There are four law classifications by which clinics’ owner, staff and medical coder must operate – common, statutory, administrative and case law. They can be confusing and vague, but it’s essential that clinicians become familiar with each.

A practice is considered common law if it’s accepted as fact by the majority of the population. Common law practices don’t have the force of a governing entity behind them.

Statutory law is legislative in nature and can be created at the local, state and federal level. Administrative law encompasses sets of rules made by government bodies or officials that allow them to administer statutory laws. Case law is made by courts when they interpret administrative and statutory laws.

The penalties for loose lips are severe.

The penalties for breaking confidentiality not only by the medical coder but the rest of the practice staff are significant, far reaching and determined through civil law if a patient decides to sue. The court can rule to award monetary amounts to clients for medical expenses, lost wages and distress. In civil cases, some practitioners choose not to go before a jury, admit no guilt, and settle out of court for a specified monetary amount.

Medical coder may find themselves facing misdemeanor or criminal penalties for their lack of discretion, as well as the clinic owner by extension.

The consequences are fines and jail time for a misdemeanor. Those who violate HIPAA standards could serve jail time for a felony. Fines in such cases have ranged from $50,000 to over $4 million.

Medical coder must treat each client’s data as highly confidential, even if it seems that a particular bit of information is common knowledge.

Stay vigilant

Patients must give permission before their information is shared and they must designate with whom. Those medical coder or other members of the practice who violate HIPAA codes in any way must be prepared for the consequences.

Failure to adhere to HIPAA regulations will result in litigation that can damage a practice so severely that it never recovers.

Even if everyone, including the medical coder involved, are found innocent, clinicians will contend with a loss of reputation, clients and revenue.

No matter how skilled a coder is at efficiently submitting claims, it’s not worth the risk if he or she doesn’t come equipped with a superior set of ethics.

Supply, Demand, and Combatting Limited Reimbursements of Insurance

by Nitin Chhoda PT, DPT | Apr 28, 2019 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

The way healthcare insurance is viewed and paid for has evolved significantly over the last century and the law of supply and demand is the rule of the day.

The business of selling insurance is a multi-million dollar industry, the sole purpose of which is to make money for the company providing the services.

Patients no longer visit their local insurance provider to obtain coverage. Insurance is packaged and sold like cars and the latest deodorant through state-of-the art advertising agencies.

Supply and demand dictates that if there’s a consumer need for a service or product, someone will provide that product or fill that need.

The Law of Supply And Demand

Consumers mistakenly believe that as more customers enter the market and purchase insurance, the cost will eventually go down. In a capitalistic system, that’s not necessarily true. If the revenues to be made are great enough, the cost will continue to increase as insurance providers strive to make ever greater profits.

Healthcare insurance providers charge the maximum amount that the market will allow for premiums.

The result is that consumers pay more for their healthcare insurance and malpractice insurance continues to skyrocket for medical professionals. Practitioners must charge sufficiently for their services to cover these costs and make a profit, while remaining competitive enough to attract new clients.

Payments versus Actual Costs

Healthcare insurance typically pays hospitals, labs and medical providers a set fee for services. In many instances, that payment doesn’t cover the actual costs involved.

Medical professionals must then decide if they will accept the insurance reimbursement as full payment, bill the difference to patients and face additional costs involved in collecting the debt, or if they want to offer the service at all.

To offset costs, medical providers need to create multiple revenue streams. Depending upon factors that include geographic location, clientele, patient load and availability, clinicians can do this through a wide variety of means. They can charge parking fees, write a book, schedule speaking engagements, add new services or develop new products.

Playing the Money Game

The primary way practitioners are paid is through reimbursement claims, which is normally prepared by medical billing professionals, to insurance companies, but there’s a dirty little secret lurking in the shadows. Insurance companies invest the funds they collect from clients to make more money. Each month that the firm can retain those funds, the company makes more on its investments.

That means healthcare providers are often forced to wait for up to three months to be reimbursed for their services. Insurance providers have teams of specialists whose job it is to calculate the fair market price for medications, office procedures and surgical interventions.

Insurance companies say these teams are eliminating waste, but the truth is that their job is to identify ways to reduce reimbursements paid to medical professionals.

Clinicians who choose not to offer specific services run the risk of losing clients to competitors who do.

If they accept insurance company reimbursements as the total payment for services rendered, they lose money.

Increasing patient numbers is one way to grow a clinic’s revenues, but creating multiple revenue streams is the most desirable. Funds coming in from a wide variety of sources will benefit practices in times of feast or famine.

Healthcare Insurance Simplified – the Patient’s Perspective of Health Coverage in the New Economy

by Nitin Chhoda PT, DPT | Apr 14, 2019 | Healthcare Practice Management, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Management

Although healthcare insurance can be useful in the case of illness, many people do not understand their insurance coverage and limitations.

Nitin Chhoda shares the different perspective of healthcare insurance; from that patient’s point of view to the healthcare service provider.

Patients and therapists view healthcare insurance from an entirely different perspective.

For patients, it’s a way to defray costs when they require a wide range of services, from prescriptions and hospitalization to well patient check-ups and ongoing physical therapy treatments.

For therapists and healthcare practice management providers, healthcare insurance is the primary means of reimbursement for services.

Healthcare Insurance

Older clients, parents and those who have experienced the need for an extended hospital stay are well acquainted with the value of maintaining a comprehensive healthcare insurance policy. They may complain about the cost of premiums, copays and deductibles, but they know the benefits far outweigh the monetary sacrifices they may make to keep their coverage up to date.

Younger individuals tend to eschew healthcare coverage or purchase less than they need. For this demographic, accidents and healthcare emergencies are incidents that happen to “other” people.

The entire healthcare insurance industry is a mystery to most patients. They’re unsure of exactly what they’re paying for, the terms of their coverage and their financial responsibility.

Healthcare insurance is often far more expensive than they anticipate, may not cover a wide variety of treatments and procedures, and involve high deductibles that must be met before coverage is available.

A Patient’s Perspective

Millions of individuals across the nation live in constant fear of becoming ill, injured or incapacitated, even when they have insurance. When they do become ill, it may be difficult to find a healthcare insurance provider that accepts their brand of insurance.

Patients often delay treatment, spreading potentially dangerous diseases. When no other option exists, those same clients resort to emergency room treatment that contributes largely to the increasing cost of healthcare costs.

As it exists, the healthcare industry in the U.S. forces patients to make decisions that can radically influence their lives and future finances.

The Affordable Care Act provided coverage to millions who were uninsured or underinsured, but it also created a deficit of healthcare insurance providers in relation to the number of new patients coming into the system.

Those who don’t understand their coverage represent a major loss of income for therapists. When claims for non-covered expenses are rejected, patients must pay the bill and collecting those funds can be a costly endeavor.

The first steps in healthcare reform have been taken, but more must be accomplished. The future of healthcare insurance in the new economy will require patients to pay more for their healthcare coverage and shoulder more of the financial burden in terms of co-pays and deductibles.

Coverage and Limitations

Coverage caps and limitations could very well become the norm. For therapists, the result of such trends is a loss of income and a potential move toward more self-pay patients, a strategy that could effectively eliminate many from the healthcare system and cost practices in the long-term.

The experience and expertise of a good therapist can’t be understated and they deserve to be compensated for that acumen. Therapists are the chief advocates for their patients’ needs, but are often forced by healthcare insurance companies to accept far less for their services than the actual value or are second-guessed by insurance company officials.

It’s neither an efficient or cost effective system, and one that can potentially place patients in harm’s way while contributing to a system that makes it increasingly difficult for therapists to operate a financially sound practice.

Healthcare Insurance and Health Insurance – What Are They?

by Nitin Chhoda PT, DPT | Apr 7, 2019 | Healthcare Practice Management, Physical Therapy Billing, Physical Therapy Documentation

Nitin Chhoda explains the health care insurance, its providers, the Insurance coverages and the Affordable Care Act for patients.

He also discusses the importance of knowing the limitations of patients’ insurance so that patients and service providers know what to expect at the time of treatment.

Healthcare practice management costs that continue to rise and unforeseen medical emergencies are the two overriding reasons individuals buy healthcare insurance.

Essentially, patients purchase insurance against the risk of becoming ill or encountering a potentially expensive and unforeseen medical need.

Accidents and catastrophic medical emergencies happen in the blink of an eye. Healthcare insurance helps defray patient costs and insures healthcare providers receive payment for their services.

Insurance Provider

Patient healthcare insurance is most often provided through an individual’s employer. Business owners contract with insurance companies to provide an established range of healthcare services that can include hospitalization, vision and dental coverage, along with office visits, prescriptions and lab tests.

Available coverage varies widely, with employers shouldering a major portion of the costs while the individual is responsible for co-pays, deductibles and monthly premiums. Medicaid and Medicare represent another form of healthcare insurance. Medicare is administered through the federal government.

Medicaid is funded through federal and state governments and distributed at the discretion of each state. Medicare is accessible by retirees and the disabled. Medicaid typically covers low-income children and adults with no other available options.

Insurance Coverages

Dwindling funds and budgetary concerns have led to coverage limits in both Medicaid and Medicare, making it essential for therapists to verify a patient’s coverage before treatment.

There’s been a push by healthcare insurance providers and employers for patients to shoulder more of the monetary burden of their healthcare, giving rise to a wide variety of special clauses and exclusions in healthcare policies.

Cancer, long-term healthcare needs and disability claims are costly for insurance providers and many policies now require clients to purchase additional, specific coverage for certain conditions. The result of shifts in healthcare insurance policies and practices has resulted in a lack of sufficient coverage for much of the population.

Underinsured clients and those with no coverage present a major problem for therapists who must balance the desire to practice their profession and render aid to those in need, with operating a practice that remains solvent and profitable. The first line of collections when a patient receives treatment is the healthcare provider.

To ensure reimbursements are received in a timely manner, practitioners submit claims to the patient’s insurance provider.

Any amount not covered through the client’s healthcare plan is the responsibility of the patient. It’s essential for therapists to determine a client’s coverage before the time of treatment to ensure the patient receives necessary services and clinicians obtain the payment to which they’re entitled.

The Affordable Care Act

The Affordable Care Act extended medical coverage to millions of individuals who previously had no insurance, but significant limitations and gaps in available services still exist.

Clinicians must ensure they have current insurance information for every client they treat before the patient arrives at the office.

It’s an unfortunate reality, but the direction of current insurance company policies may force therapists to decline patients with limited or no coverage to ensure their practice isn’t at financial risk.

Insurance companies represent the first line of reimbursements for clinics, followed by state and government programs, and self-pay patients. Changing and evolving healthcare insurance will require practice owners to examine the state of their businesses and the patients they treat with an increasingly stringent set of criteria.

Medical Billing And Coding Outsourced

by Nitin Chhoda PT, DPT | Feb 17, 2019 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

Medical billing and coding are indeed a very complex subject. It is important to analyze whether your practice will need an in-house medical biller and coder or have it outsourced.

Nitin Chhoda gives some factors to consider in order to guide your physical therapy practice when it comes to your medical billing needs.

Outsourcing often increases efficiency, especially in technical fields like accounting and medical billing and coding.

Within a single office, a number of practices can be serviced by a handful of highly skilled professional medical billers and coders.

They can focus all of their resources and attention on efficiency and a system that works. At a medical clinic, the primary focus is often the patients, as it should be.

Reasons to Outsource Your Medical Billing and Coding

Here are some very good reasons that a practice should consider outsourcing medical billing and coding. For the most part, the decision will be financial. But to determine whether or not it will be worthwhile for your practice to outsource can be so complex that identifying key reasons to outsource will help.

You’re New

New clinicians or health care providers have a whole host of things to worry about. How do you maintain a steady stream of patients?

Does your practice have the in-house testing capabilities necessary for the needs of the community? How do you balance the business side with patient care? How many hours per day should you be seeing patients?

Probably the top concern is how your patients are doing, how they feel about you, and whether or not you’re helping them. Managing a business at the same time as you’re learning what it means to run a private practice can be overwhelming.

Staff Turnover is High

If you are handling in-house medical billing and coding, but have to hire a new biller or coder regularly, your practice will suffer.

The learning curve for medical billing and coding is unforgiving and even a skilled medical billing and coding professional is going to be slow to start as they figure out your particular system. For practices that can’t seem to keep medical billing and coding staff members, a consistent service from elsewhere will be more efficient.

Inefficiency is Obvious

Outsourcing has a couple of major benefits, and one of them is that rejections and denials are usually decreased when you outsource medical billing and coding.

If you are experiencing problems with collections and your rejection and denial rate is high, it may be time to consider giving the job to a service that specializes in getting claims accepted.

You Don’t Want to Focus on Billing

Chances are, you don’t want to think about medical billing and coding. As critical as getting paid is to the health of your practice, if you became a doctor because you want to help people feel better, billing is probably an annoying part of your job.

Not to mention the fact that an incredible amount of tech savvy and skill is required to make your medical billing and coding system efficient and effective. Many clinicians decide that the billing side is the part they don’t want to know about – they’d prefer to let someone else worry about the medical billing and coding courses so they can continue to provide a service to the community.