practice management

What are the Medical Billers?

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

Medical insurance billers (MIBs) are the lifeline of a well-funded practice and the connecting link between patients, practitioners and insurance companies.

Billers affect the lives of hundreds of people each week and are an essential link in the reimbursement process. They collect payments for clinicians and ensure that insurance companies pay their portion of the costs for their clients’ healthcare expenses.

Medical billers perform a variety of functions, from entering the alpha-numeric ICD-9 and CPT codes that tell insurance companies the treatment a practitioner provided to interacting with patients on the balances they owe.

Medical billing staff works with sensitive data each day that requires confidentiality, integrity and ethics.

First Step — Data Collection

An MIB often functions as a coder and a biller, though the jobs can be exclusive of each other. Medical billers gather all the information associated with a patient’s encounter with their healthcare professional.

That information provides the documentation that will be used to support the payment requested from insurance carriers.

They decipher the data to determine the patient’s complaint and the appropriate CPT code to reflect the treatment provided.

Medical Billers Should Have Good Communication Skills

Medical billers spend a considerable amount of time interacting with others as part of the data collection and payment process. Clinicians must be queried to clarify patient encounter information and patients contacted about their payment obligations.

Medical billers also interact with insurance company representatives on reimbursement issues.

MIBs Must Always Verify the Facts

Medical billers are responsible for verifying patient insurance information, the correct billing format for each payer, and assigning the codes and modifiers that result in the practitioner’s payments.

They work with hard facts about patient policies, physician services and insurance company protocols.

Medical billers may also transcribe a doctor’s dictation about the patient encounter. Billers are knowledgeable in medical terminology, which helps them in assigning diagnosis and procedure codes.

Medical Billers Must Have Computers and Integrated Software

Medical billers spend a majority of their time behind a computer screen, ascertaining the facts of each patient encounter. They work with specialized billing software, like In Touch Biller Pro,or electronic medical record (EMR) systems, like In Touch EMR, that assist them in coding correctly, meeting the many submission demands made by payers, and transmitting claims electronically.

Consistent in Following Up Funds

Medical billers track and monitor each claim to determine its position within the reimbursement process.

They submit claims to clearinghouses where they’re examined for mistakes, errors and inconsistencies.

Clean claims are forwarded on to payers for reimbursement.

Medical billers track and monitor each claim to determine its status, ensure payments are made in a timely manner, and deposited in the practitioner’s account.

They work with clearinghouses and carriers if a claim is denied to obtain payment, and interact with patients on co-pays, deductibles and balances owed.

IMPORTANT: Medical billers ultimate responsibility is to ensure that clinicians collect the maximum amount of money to which they’re entitled.

Medical billers wear many hats in their profession. They’re often one of the first and last individuals with which patients interact on financial obligations, and they comprise the key element in the reimbursement chain.

Medical billers document, code, transmit and follow payments to ensure their client’s financial status remains in the black.

Claim – How to Appeal When Denied

by Nitin Chhoda PT, DPT | Nov 9, 2013 | Electronic Medical Records, Healthcare Practice Management, Physical Therapy Documentation, Physical Therapy Management

Each reimbursement claim goes through an adjudication process once it reaches a clearinghouse and eventually, every biller will receive a denial.

Depending upon the reason, healthcare providers can appeal the decision and MIBs will play a major role in the process. In this enlightening article, well known physical therapist, Nitin Chhoda, explains how to resolve disputes without going through an official appeal.

Many claims are denied for oversights and mistakes that can easily be rectified. Winning payment for their clients requires MIBs to develop an appropriate strategy that addresses the cause of the claim denial.

The first step is a written communication that demonstrates exactly why the claim denial was made in error. The following are some important factors to consider when appealing a denied claim:

Active policies
Improper submission
Level of care
Medical necessity
Networking problems
Pre-authorization
Pre-existing conditions
Procedures that are not covered

Proof the Patient’s Policy is Active and In Effect

When new insurance coverage goes into effect, the information may not have been added to the clearinghouse database. Proof must be provided that the patient’s policy was active and in effect at the time of treatment.

This can be accomplished with a copy of the valid insurance card or a letter from the patient’s employer that provides the pertinent information.

Adhering to the Payer’s Reimbursement Submission

Each claim undergoes close scrutinization. Individual insurance companies have their own policies, procedures and protocols for reimbursement submissions.

Not adhering to these will generate a claim denial, but can generally be fixed by correcting any error or making the appropriate revisions and resubmitting the claim.

Required Level of Care

A carrier may decide the level of care exceeded what was required. Supplying supporting documentation for the claim will usually clear up the matter.

Is the Medical Necessary?

It’s the responsibility of the practitioner to prove through appropriate documentation that the treatment or procedure provided was medically necessary. The clinician must provide a written letter that explains any extenuating circumstances.

Network Unavailability

Payer policies may require patients to only see specific practitioners within their network of participating providers for treatment to be covered. Clinicians need to explain if an in-network provider wasn’t available.

Circumstances of Missed Preauthorization

If a preauthorization wasn’t obtained prior to treatment, explain to the payer the circumstances that prevented the request, such as a medical emergency. The clinician should also supply evidence that the authorization would probably have been approved anyway.

Pre-Existing Conditions

Many policies have exclusions for any disease or condition that affected the patient prior to when their policy went into effect.

To eliminate a claim denial, the onus is on the medical provider to demonstrate that treatment wasn’t due to a pre-existing condition.

If available physical therapy documentation doesn’t support this, an appeal is futile.

Procedures Covered or Not Covered

Each insurance policy has specific restrictions, requirements and limitations. MIBs will need to ensure that the claim was coded correctly and the procedure was covered. If the coding was accurate but proof of coverage can’t be assembled, don’t appeal.

An appeal isn’t always indicated when a denial is received. When all the requirements, coding and conditions of the policy has been met and a denial is issued, it’s important for the MIB to provide the needed documentation and evidence to support the reimbursement.

These strategies provide carriers with clear and logical explanations as to why the denial should be removed and funds facilitated to the practice’s account.

Billing and Coding Errors – How to Minimize If Not Avoid

by Nitin Chhoda PT, DPT | Nov 6, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

The Affordable Health Care Act resulted in many changes for subscribers and alterations in the services carriers are willing to cover as part of insurance policies.

Those modifications directly impact how medical insurance billers (MIB) code claims. To assist billers in avoiding costly billing and coding errors, Nitin Chhoda examines the most common reasons for claim rejections and denials.

To make payroll or purchase equipment and keep a practice operational, clinicians rely on MIBs to provide a steady stream of income in the form of reimbursed claims.

When the flow of revenue is interrupted with rejected or delayed claims due to coding errors, it can spell hardship for the practice and result in an investigation by regulators and law enforcement for suspected fraud.

Assumption of Coding

Every patient encounter is different and MIBs should never code on the assumption that “standard” treatment was provided. Billers need to consult with the clinician if they suspect missing information or simply can’t read the physician’s handwriting.

Documentation Problems

A number of documentation problems can arise when claims are filed, including missing or incomplete documentation that supports each item for which the practitioner is seeking reimbursement.

A criminal investigation could be done in the immediate future if a payer believes the MIB altered or recreated documentation to support a denied claim.

Mismatched Coding

The incidence of mismatched coding is a careless mistake and happens more often than one would imagine. It most frequently displays as billing a male patient for a treatment or procedure that is unique to female anatomy.

Important note: You can never overlook such simple mistakes because it can lead to claim denials.

Noncompliance

Each insurance carrier establishes its own set of rules and regulations governing claims. Billers can expect a denial if they don’t adhere to the payer’s specific policies, procedures and protocols.

Preapprovals

MIBs who fail to obtain the appropriate approval prior to treatment will find the practitioner’s claim denied. Payers are sometimes willing to make the approval retroactive in the event of an emergency when treatment was critical to save a person’s life.

Truncated Coding

Claims must include all three diagnosis levels for the greatest accuracy. Truncated coding may address the manifestation and episode of care portions, but not include the site of infliction.

Up and Down Coding

Coding at a higher level of treatment than was received exposes practitioners to fraud charges. Down coding is billing at a lower rate than appropriate in an effort to avoid denials. Payers who suspect this of happening can hold up claims for weeks or months.

Unbundling

Coding is designed to include multiple actions as part of specific procedures and is billed as a whole. Unbundling bills those elements separately and could be viewed as an attempt at fraud.

Practitioners place their faith in MIBs to do their jobs quickly, efficiently and ethically. Mistakes in your physical therapy billing and coding can be easily rectified by simply double checking each claim before transmitted.

Being “creative” by unbundling or making assumptions about treatment that’s not supported by documentation can lead to charges, fines and litigation against both the clinician and the biller. Taking an extra moment to examine the claim will save days or even weeks in terms of delays and denials.

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.

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.