healthcare and insurance

How to Get the Claim: The Billing Scenario

by Nitin Chhoda PT, DPT | Sep 21, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing

Building a clean claim is a concerted effort. It begins with the office staff that gathers demographic information and comes to fruition when the funds are deposited in the practice’s account.

Much can happen to a claim on its way to becoming a payment and in this informative article, Nitin Chhoda provides unique insights into the pitfalls that face even perfectly prepared claims and elements that affect payment.

Where’s the Claim?

Aside from coding errors, reimbursement claims can go awry in many ways. The insurance provider may not be known at the clearinghouse or the clearinghouse software may glitch and submit the claim to the wrong provider.

In some instances, the payer may not be using electronic medical record (EMR) software necessitating submission of a paper claim.

Verifications

Practices that utilize EMR technology receive a report in real time when a claim has been submitted. These receipts provide billers with critical information in the event of a problem. Occasionally, a claim will appear to vanish into the ether.

Clearinghouse reports tell billers when the claim was received, its status and if any problems were identified. If payment isn’t received in a reasonable time or it doesn’t appear on the biller’s daily verification, that data be used to track down the claim and rectify any problems.

Reimbursement Amounts

The whole point of submitting claim is to get paid, but the amount charged can conflict with what the payer is willing to reimburse. When differences occur, billers can easily refer to the contract the clinician has with the payer to define the reimbursable amount.

CPT codes are assigned a relative value that determines reimbursement amounts, derived from the Resource Based Relative Value Scale (RBRVS). The value assigned is based on the work required, the cost of maintaining a practice and the malpractice/liability for which the practitioner is responsible. A formula is then employed that takes into account geographical locations to calculate the reimbursement rate.

Prioritizing

Some contracts are RBRVS based, some aren’t, and the differences in each can be immense. Depending on how the contract is written, procedures may be paid based on RBRVS standards or discounts applied for secondary procedures done at the same time.

Some may be paid at a higher rate determined by prioritization, while others are billed according to expected payment. If the contact doesn’t state which procedure is prioritized, it’s up to the biller.

The Deciding Vote

The ultimate decision lies in the hands of the company that provides the patient’s healthcare insurance. Once the clearinghouse completes its search for errors, it forwards the claim to the payer.

When reimbursements are less than expected, billers must refer to contract terms to obtain the maximum payment allowed.

Many hazards await claims, from submission to the wrong payer to glitches in clearinghouse software. EMRs facilitate the process by submitting claims in real time and documenting receipts from the clearinghouse.

Medical billing specialists can help clinicians boost revenues by carefully monitoring claims and referring often to contract details. Practitioners must negotiate their contracts carefully to ensure their services are adequately reimbursed.

Medical Billers: The Ever Expanding Field of Medical Billing

by Nitin Chhoda PT, DPT | Sep 11, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Medical billing specialists are in high demand and the need won’t be slowing anytime in the near future. The transition to ICD-10 codes, federally mandated electronic medical record (EMR) software systems and a flood of new patients into the marketplace have all combined to create a perfect storm for skillful, experienced and certified medical billers. In this informative article, Nitin Chhoda examines the expanding field of medical billing.

Work Environments

The biggest draws for medical billers is the ability to start their own business with low overhead, work from home, and a career that can be employed from any location.

Medical billers working from home can set their own hours and the profession doesn’t have the physical requirements demanded by other healthcare fields, making it ideal for those with disabilities and stay at home parents.

Many medical professionals are outsourcing their billing activities, but the need for certified medical billers still isn’t being met. The need for medical billers is expected to increase faster than any other occupational field. A career in billing provides individuals with a decent income in a profession that’s almost recession proof.

Billers can work from home, in clinics, insurance agencies, hospitals, nursing homes and government operated public health facilities.

Easy Education

Individuals will find numerous online educational and certification opportunities that can be completed in as little as two to three months. Many professional organizations for medical billers offer courses, certification and chances to practice what they’ve learned, along with opportunities to learn about EMR technology.

New and Aging Patients

The Affordable Health Care Act changed the playing field and opened up a wealth of new opportunities for medical billers. The legislation is providing health care for millions of potential new patients, leaving providers with less time to deal with the intricacies of “paperwork”. An aging population in need of medical care is contributing to the need for medical billers with knowledge and experience of private and government-operated insurances.

EMR Technology

The use of EMR system software has been federally mandated for any entity that works with patient medical data. EMRs provide advanced methods for meeting the HIPAA standards designated for storing, retrieving and transmitting client information. The technology is changing the way billing is handled and provides medical billers familiar with the software with a multitude of opportunities.

New Medical Codes

The transition to the new ICD-10 codes has many healthcare providers worried about delays in claim reimbursement. Experience with EMRs is going to be a plus for medical billers.

Familiarity with the software will allow medical billers to transmit claims without interruption and keep the flow of cash coming into the practice.

Medical billing is a quickly expanding field that demonstrates little indication of abatement. The need is obvious, with multiple online opportunities for training and certification available. As insurance companies become more determined to avoid or delay reimbursements, skilled medical billers are essential to ensure that medical professionals obtain the payments they deserve.

Modifiers Beyond the Treatment: The OTHER Ways to Legitimately Stimulate Cash Flow

by Nitin Chhoda PT, DPT | Sep 2, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation, Physical Therapy Software

Practitioners are always seeking new sources of revenue and skilled medical billing specialists can obtain those additional funds through entirely legitimate means. Medical billing isn’t confined to simple coding procedures alone and in this insightful article, Nitin Chhoda examines ways billers can create greater cash flow for the practice.

Needful and Medically Necessary

There exists a wide range of procedures and modifiers that insurance companies don’t cover. They’re considered cosmetic and viewed as elective treatments.

Depending on the procedure, it may be possible to obtain reimbursement for some of those procedures, such as reconstructive surgery. Obese patients who have lost massive amounts of weight may require loose and excess skin to be removed.

Other clients may need dental work that can be billed as a covered expense, along with rehab services. Practitioners should remember that health concerns aren’t limited to the physical body. Patients may need the services of counselors, psychologists and psychiatrists to treat the mind.

Equipment and Pharmaceuticals

Modifiers are essential if more than one medical provider is involved and can qualify for additional payment. If it’s necessary to obtain lab work, an x-ray, MRI or similar diagnostic services, chances are the patient will be sent to another provider or facility. Equipment owned and maintained by another entity can be billed using modifiers.

Unbundling Advantages

Procedures that require extra skill, effort and time may qualify for additional reimbursement. Medical billing staff can billed specific services separately through the application of the appropriate codes, edits and modifiers. Practitioners may find that they must perform a second procedure while conducting another. Sometimes the two can be linked, but not if the second procedure is essential to the first.

Modifiers and Edits

Sometimes the difference in reimbursement is as simple as adding the correct modifiers to explain the full extent of the clinician’s services.

For instance, clinicians who make a simple diagnosis of a head fracture will receive much less in reimbursements than a practitioner that enters a diagnosis of a closed head fracture with contusions and lacerations. Each diagnosis is correct, but one provides greater detail and modifiers, allowing billers to enter that information in a way that generates a larger reimbursement.

Same Day and Multiple Treatments

Patients no longer rely on a single healthcare provider for all their needs. When a client sees multiple clinicians on the same day, modifiers are sometimes necessary to indicate each practitioner provided different services

Modifiers indicate a change or alteration in how a procedure or service was delivered. When use of modifiers is justified, it can mean a difference in hundreds and even thousands of dollars each year in additional revenues. They must be utilized judiciously. If not, it can result in paybacks and even legal action.

Supplies, Consultation and Time-Based Coding

A bandage may seem like a small concern, but some clinicians are depriving themselves of income by not including medication and supplies that are dispensed in the office.

The same is true when practitioners provide patients with counseling about medications, treatment options, and coordination of care that accounts for 50 percent or more of the patient encounter.

A complete accounting for the time spent must be documented to prove the service was necessary

One of the largest concerns of payers is fraud and inflated claims. They’re job is to find ways not to pay claims, or as little as possible, which often leads to underpayment for clinicians. With justified use of modifiers and edits, unbundling and hour-based billing, billers can legitimately stimulate significant cash flow for any practice.

Medical Billing Professional Groups and Associations – A Useful Tool

by Nitin Chhoda PT, DPT | Aug 29, 2013 | Electronic Medical Records, Medical Billing, Physical Therapy Billing, Physical Therapy Software

Professional groups are an important element for medical billing specialists. They provide professional information, support and assistance, allowing billers to remain cognizant of rules, regulations and changes within the profession. In this informative article, Nitin Chhoda examines the advantages of biller-related associations and groups.

Education Opportunities

There are a number of organizations with a focus on the medical billing profession.

The groups offer an extensive array of services, from classes to achieve certification to continuing education for those who have already attained employment.

The organizations advocate for higher wages and conditions within the work place.

Many classes are provided online, allowing medical billing staff to study when it’s convenient without interrupting their employment. Those working to become certified medical billing professionals can attain their credentials through accredited classes and programs.

Aspiring billers can familiarize themselves with terminology, legal issues, anatomy and physiology, and dealing with payers.

Industry Changes

Standards can change quickly within the profession and the groups distribute industry information to help medical billing professionals keep abreast of the latest updates and changes. One of the most important changes is the transition from ICD-9 codes to ICD-10 coding and billers can learn how the changes will affect them, accepted medical billing practices and the benefits. Some groups even provide online trainers, along with in-depth information on maintaining HIPAA-approved security.

Conferences, Conventions and Supplies

Professional medical billing associations conduct an extensive number of conferences, conventions, seminars and webinars, and exhibitions on all aspects of the industry. The special events provide medical billing people with information and demonstrations on new products, methods and industry trends, along with educational opportunities and technology.

Budding billers have access to starter programs, medical billing software, and practice programs to familiarize novices with the type of forms and information with which they’ll be working. Books and manuals on HIPAA compliance and associated computer tools are offered.

EMRs and Technology

The Affordable Health Care Act has mandated the use of electronic medical record (EMR) technology to maintain patient records and facilitate medical billing. Professional biller organizations offer extensive data on EMRs, their benefits and information on what to expect when working with the integrated software systems.

Professional medical billing associations and organizations assist individuals obtain credentials and provide ongoing information on all facets of the profession.

The groups provide essential services and products for billers at all levels of expertise.

The groups are committed to providing recognition for member contributions, continuing education, networking among peers and advocating for wages appropriate to the individual’s level of education and experience. They’re important resources for those considering a career in medical billing and those who are already professionals in their field.

Billers Working With Payers: Your Pain, Their Gain

by Nitin Chhoda PT, DPT | Aug 26, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Billers work hard to collect the reimbursements to which clinicians are entitled and healthcare insurance providers work equally hard to delay or reduce those payments.

It requires more data, phone calls and effort on the part of billers to collect even basic amounts. In this revealing article, Nitin Chhoda examines the insurance game and how to be on the winning side.

Insurance companies are in business to make money. When they make reimbursements, they view it as losing money.

As a result, insurance companies have reduced the amounts they pay medical providers for services, have become inventive at delaying reimbursements, and adept at utilizing a variety of techniques to deny payments.

EMR Assistance

Reasons for rejections come in many forms and electronic medical record (EMR) software is the first step in combating short or rejected payments. The software systems transmit claims electronically, ensuring they arrive at clearinghouses promptly and provide billers with an ongoing status record of each claim submitted.

EMRs can detect potential problems that could result in a rejection, allowing billers to submit clean claims that are processed quickly. The systems aid billers in submitting the appropriate forms to the correct clearinghouse and alert billers when a claim has been accepted or rejected. EMRs provide billers with a complete system for claim management.

Learning the Ropes

The techniques used by insurance companies to deny claims or pay at lesser rates are designed to keep money in their coffers for as long as possible. Quick submissions combined with meticulous documentation are essential when submitting claims and disputing rejections.

Collecting full and timely payments is much like a cat and mouse game, but billers that learn the “rules” are able to collect reimbursements quickly and cleanly that requires a minimum of follow-up.

Winning the Insurance Game

Dealing with insurance companies isn’t for the faint of heart. Denials can be issued for legitimate reasons, such as using the wrong form, not including sufficient documentation, a clerical error or a glitch in clearinghouse software. Organization and quick attention to denials often result in a successful conclusion.

Billers must submit claims within 72 hours whenever possible. If the problem is insufficient payment, an error can be corrected and the claim resubmitted. It’s important that the payer is aware that the claim isn’t a duplicate.

Submit documentation to specify what the error was and the correction. Another beneficial tactic is to submit claims ranked by charges and don’t include documentation unless asked. The needed information is included in the claim.

If attempts to rectify the problem are met with silence or delays, make the patient an ally. Inform the client and let him/her take the battle to their insurance company for a quick resolution.

Policy holders expect their insurance company to pay for appropriate expenses and not leave them holding the bag. Unhappy customers talk to others and insurance companies don’t want to lose clients.

Quick medical billing claim submissions, EMRs and enlisting the assistance of patients are legitimate means of winning the reimbursement game with insurance companies that procrastinate and underpay. In most situations, the payer holds all the cards, but billers can turn the tables and make the payer’s pain the clinician’s gain.

How Clearinghouses Can Save You Time and Money

by Nitin Chhoda PT, DPT | Aug 23, 2013 | Medical Billing, Physical Therapy Billing, Physical Therapy Documentation

Practitioners of the medical arts are always seeking ways to reduce costs while continuing to provide the best level of patient care possible.

Three ways that practices can accomplish this is by contracting with the best payers, utilizing clearinghouses to process claims, and implementing an integrated electronic medical record (EMR) system. Nitin Chhoda examines the advantages and savings for clinicians in this informative new article.

Millions of reimbursement claims are transmitted digitally each day via EMR technology. They arrive at their destinations in real time and each is documented by one of several clearinghouses located throughout the nation.

Technological advances have done away with the need for postage stamps, paper claims and waiting weeks for approval or denials.

Secure Transmission

Electronic data interchange (EDI) allows practices to transmit reimbursement requests and supporting documentation to clearinghouses in a secure format that meets HIPAA requirements. It’s part of the abilities inherent in EMRs.

Billers can verify electronically that clients have met their responsibilities for any co-pays to help speed the claim along.

Destination Locations

Practitioners contract with insurance companies for payment and all submissions are sent to a specific clearinghouse where they’re scrubbed for any errors or mistakes. Clearinghouses handle a multitude of claims each day and clean claims are forwarded to the appropriate insurance company for payment. Clearinghouses and billers work together to meet the specific formatting requirements of each payer.

Clearinghouses deal with multiple medical providers and insurance companies at once, eliminating the need to bill each insurance company individually. Some charge flat fees or a fee per transaction for claims that are processed. The benefits far outweigh the costs, providing clinicians with a quick and reliable way to transmit claims, verify receipt of those claims, track their status and monitor payments.

Collecting Payments

Working with clearinghouses ensures that reimbursement claims are dealt with quickly for faster payment to physicians. Reimbursements can be electronically transferred to practice accounts in as little as 10 days.

Medical billing team and practitioners should keep in mind that even after a claim has been scrubbed at the clearinghouse it may still be rejected by the insurance company.

It’s the job of insurance carriers to find ways to deny claims. It’s how they make money. When a dispute arises, EDI allows practitioners to quickly discover why a claim was rejected and provide any additional documentation.

Billers can refer to the contract terms between the clinician and the payer and initiate communications to rectify any problems.

Clearinghouses work with multiple payers and millions of claims each week, speeding reimbursements on their way to their appropriate destination, saving practitioners time and money. They assist in verifying and sorting claims, allowing clinicians to collect reimbursements quicker than ever before and are an essential element in the payment process.