Documentation is the backbone of a medical insurance billing (MIB) business. It’s essential to file claims for clients and interacting with the IRS at tax time. In this informative article, Nitin Chhoda reveals the many reasons for maintaining proper documentation within an MIB business.

Tools of the Trade

Billing software is designed to handle virtually any billing related task an MIB chooses to offer, but MIBs should consider the option of employing electronic medical record (EMR) technology in their business.

Fully functional EMR software is available for free and only requires a modest monthly user fee.

EMRs are in compliance with HIPAA privacy standards and submit claims electronically. They have the ability to maintain multiple databases for any number of patients, providers and payers. The billing software maintains a comprehensive array of information digitally or in the cloud, eliminating the need for paper medical records.

Avoiding the Litigation

Perhaps the greatest need for documentation in a biller’s arsenal is to avoid running afoul of litigation on behalf of their clients. It offers protection against accusations of billing for services and procedures that weren’t provided, altering or falsifying claims, misrepresentation, and billing for non-covered services.

Daily Documentation

Armed with a medical provider’s day sheet, MIBs are tasked with submitting a client’s current claims, complete with the necessary patient data.  Documentation must be kept that supports the medical provider’s diagnosis, treatment and procedures performed when claims for billing are sent.

It’s a simple matter to import written records into an EMR for storage and easy retrieval should a claim be denied, rejected or need correction.

Billing software provides a running account for each client that documents which claims have been paid, patent balances owed and payments posted to a clinician’s practice. Billers can quickly refer to their software when dealing with clearinghouses, payers or recalcitrant patients.

Patient IDs and Coverage

A patient must provide a photo ID and a copy of their insurance card for a claim to be filed. All that information can be kept securely within billing software, allowing billers to update the data as needed. Copies of all those insurance cards provide billers with necessary information to submit claims that get paid in a timely manner.

The billing documentation provides essential information about the client’s medical coverage, insurance exclusions, co-insurance, deductibles and co-pays, and who is covered, along with any financial maximums or caps. The documentation contained within the software allows billers to ascertain if the patient’s coverage requires pre-approvals or referrals.

Contracts and Databases

To deal with clearinghouses with authority, billers need a copy of the contract between clients and their clearinghouse. Digital documentation puts the necessary information at their fingertips.

Multiple databases can also be created to provide an array of information that billers have agreed to track for their clients, from referral sources and revenues to the number of procedures performed each month.

Operating Costs

Documentation and receipts are critical for billers at tax time. The data allows MIBs to claim the cost of operating expenses, from equipment replacement and depreciation to loan payments, office supplies and coding updates. Don’t forget to document income.

With the elimination of paper forms, digital documentation becomes a critical element in business, especially in the medical billing industry. Billers who want an affordable full management system that will grow with their business should consider an EMR for comprehensive documentation, storage and retrieval.