Insurance Eligibility and Claims Submission: Push-Button Type

Insurance Eligibility and Claims Submission: Push-Button Type

Years ago patients’ insurance eligibility took weeks or months to determine. Now, with the help of electronic medical records, verifying insurance claims happen at the touch of a button. 

Nitin Chhoda describes the push-button feature technology that EMRs are providing in order to streamline the physical therapy documentation process.

insurance eligibilitySubmitting reimbursement claims is one of the most important tasks in a physical therapy documentation process.

It’s also one of the most time consuming, fraught with multiple opportunities for audits, denials and requests for additional information.

Those who have implemented an EMR know first-hand that errors and mistakes can be virtually eliminated through push button claim submissions and insurance eligibility.

EMRs Role to Claims Submissions

EMRs offer the most sophisticated means available to submit claims and verify the insurance eligibility of any patient.

A tablet-compatible EMR allows clinicians to tap a button to submit claims singly or as a batch.

Therapists utilizing an EMR can verify the insurance eligibility and coverage of any client with push button functionality. They can also identify claims that could be red-flagged by insurance providers.

Push-button claims submission allows clinic owners to submit reimbursement claims to a wide variety of payers, from private insurance and military insurers to Medicare and Medicaid.

Physical Therapy Software

Physical therapy management software simplifies and expedites the claims process for reimbursements that are less likely to be questioned and payments that reach the practice’s account quicker. An EMR can be integrated into existing insurance eligibility office systems and streamlines the entire billing process and workflow.

Refiling claims, denials, and responding to requests for clarification and more insurance eligibility information cost practices untold hours of work, effort and lost or late revenues. EMRs use the power of the Internet to file claims in real time that arrive almost instantly, allowing the adjudication process to progress quicker for better cash flow to the clinic.

Push-button claim submissions provide the means for practice owners to send reimbursement requests from the office and any venue where clinicians provide their services.

HIPAA Compliant

The insurance eligibility systems are HIPAA compliant and offer an enhanced level of safety and security for sensitive information. EMRs make it possible to have a patient’s office visit ready for billing even before they leave the building. EMRs provide another essential service for physical therapy clinics.

insurance eligibility and claims submissionThey allow practices to verify a patient’s insurance eligibility and coverage for services with push button technology.

In a time of economic flux, insurance companies and other payers are examining claims closer than ever before.

Insurers are reducing available services to clients and placing monetary caps on the amounts for which they’ll pay. Many patients aren’t aware of the limitations associated with their insurance coverage and are taken completely by surprise when they find out.

Push-Button Feature

Practice owners with an EMR can utilize the push-button feature of an EMR to ascertain if a patient is eligible for coverage, if there are limits on services or monetary amounts, and required co-pays. That feature alone can save clinicians thousands of dollars each year.

People change jobs and lose their insurance, and healthcare coverage is at such a premium in the U.S., that there’s even an active market in insurance identity theft. An EMR provides the tools for clinics to immediately verify insurance eligibility and protect themselves from those who would obtain services to which they’re not entitled.

Push-button technology assists therapists verify a client’s healthcare coverage, and submit reimbursement claims with alacrity and ease for practice profitability. Push-button claims submission and insurance eligibility allows practice owners to submit billing in real time, virtually eliminate errors that slow down reimbursements, and increase cash flow.

That same technology helps therapists determine a client’s available coverage to provide better patient care, while protecting themselves from those that would cheat the system and therapists of their rightful payments.

Insurance and Benefits for the Average Citizen

Insurance and Benefits for the Average Citizen

Healthcare insurance is not affordable for most, especially to the average citizen. Nitin Chhoda shares the role of The Affordable Care Act and how the average citizens can benefit from its coverage.

insurance and benefitsAccording to a Sept. 2012 study by The Kaiser Family Foundation, the average premiums for healthcare insurance in 2012 were $5,615 for an individual and $15,745 for family coverage.

The actual cost and available insurance and benefits vary widely throughout the U.S. and covered expenses are dependent upon the individual healthcare policy.

Many people saw passage of The Affordable Care Act as a panacea for all their healthcare insurance and benefits needs.

While the act did extend coverage to millions of uninsured individuals, the reality of their medical billing coverage and the cost of being insured came as a surprise to many.

As different facets of The Affordable Care Act are phased in through 2014, basic coverage by certain plans will encompass essential services and impose no lifetime spending limits on those services. Basic healthcare coverage will include:

  • Emergency services
  • Hospitalization
  • Maternity benefits
  • Newborn care and pediatric services
  • Mental health and substance abuse services
  • Prescription medications
  • Preventative and wellness services
  • Chronic disease management
  • Oral care
  • Vision services
  • Lab and x-ray

Until all aspects of The Affordable Care Act take effect, individuals are still contending with standard healthcare insurance policies that are often limited in scope. They may provide coverage for visits to a physician, hospitalization and rehabilitation services, along with x-rays, lab tests, immunizations and well-child visits.

Mental health and substance abuse services, pap tests, and mammograms may also be included. Insurance and benefits policies usually include prescription medications, but not always.

Coverages and Caps

A host of services may not be covered, policies can contain provisos and require clients to purchase riders to their basic coverage to receive maternity benefits, cancer treatments, dental care and vision exams. Those services require an additional financial outlay. They’re viewed as optional insurance and benefits coverage rather than part of the overall insurance package.

Current healthcare insurance policies often contain monetary caps on services, lifetime benefit limitations, and require pre-approval for an array of tests, procedures and surgeries. For the majority of Americans, healthcare insurance is offered through the workplace.

To keep costs low, employers often contract with insurance and benefits companies for policies that offer rudimentary coverage for employees, while passing on a large portion of the cost to employees.

insurance and benefitsToday’s insured are being required to take greater responsibility for their own health and engage in preventative measures in an effort to identify, diagnose and treat potential health problems before they become critical.

Along with this is the current trend by the healthcare insurance industry of moving toward requiring clients to purchase individual insurance and benefits from a menu of optional services.

The Affordable Care Act will mitigate many of the problems individuals encounter with coverage by traditional policies, but many wonder what the ultimate cost will be to consumers. Higher deductibles, copays and premiums may be looming just over the horizon for many citizens.

Selling Policies are Limited

Healthcare insurance and benefits providers are often limited to selling policies by geographic areas and are only allowed to offer insurance across state lines under a specific set of circumstances. Those boundaries prevent a truly open market for consumers and could contribute significantly to continually rising healthcare costs.

After decades of controlling the healthcare insurance and benefits industry, dictating terms, and an era of record profits, healthcare insurance providers are being forced by presidential decree to extend benefits to the majority of Americans, regardless of pre-existing conditions.

The Affordable Care Act extends coverage to millions of Americans and provides an array of essential services, but insurance providers aren’t going to give up record profits without a fight, which could lead to even higher healthcare costs for Americans.

Medical Billing Company: How It Works

Medical Billing Company: How It Works

In this article, Nitin Chhoda describes the role of a medical billing company and how it can help a private practice.

There are some important points to consider when deciding about the company you want to work with, whether to outsource and hire a medical billing company, or train in-house personnel.

medical billing companySelecting a medical billing company is a major decision and one that must be considered carefully.

Some practitioners choose to handle their billing needs on-site through their EMR, while others simply turn that aspect of their business over to a company that specializes in billing, coding, recovery and collections.

Therapists that choose that path should approach the process in much the same way they would to hire an accountant or financial planner.

The Role of Medical Billing

Medical billing is a highly specialized field and clinic owners should seek a medical billing company that employs certified medical billers that have the education and training to understand the more than 120,000 new codes involved when ICD-10 is implemented.

Insurance companies have a wide variety of requirements and restrictions, and the firm’s medical billers should have a working knowledge of them all. Clinicians should also seek a medical billing company that treats their money as if it was their own and has a proven history.

Don’t be afraid to ask for references and proof of recovery percentages, along with the average turnaround time on reimbursements and their annual write-off rates. The medical billing firm must meet and maintain HIPAA standards, work to recover the maximum amount of revenue for the clinic, and provide regular reports on the financial state of the practice.

For many physical therapists, outsourcing their medical billing needs represents considerable savings for the practice. In-house medical billing may require hiring additional staff to handle the complicated and time-intensive process competently and efficiently.

It can also require significant upgrades to the practice’s current hardware and software systems. Smaller practices may benefit most from outsourcing their billing department and it may present the most cost effective solution.The 21st century practice doesn’t rely on paper records and neither should the clinic’s medical billing company.

Medical Billing Companies

Today’s billing companies offer a variety of services that includes many of the capabilities available with an EMR, encompassing patient scheduling, client reminders, verification of insurance coverage and a 24/7 call center. They also provide therapists with information to track demographic groups, cancellations, referrals, no shows and new patients.

medical billing companyBilling, coding and collections are processes that continue to become more complex.

Hiring a medical billing company relieves therapists of a time consuming task, while providing clinicians with additional time to focus on patients and their care and an improved cash flow for the clinic.

Billing firms have the financial resources to hire the most experienced and knowledgeable staff, and purchase the sophisticated software and hardware systems.

A facet of the medical billing company that many therapists overlook is the quality of the customer care that’s provided. The medical billing company will often be required to deal directly with the clinic’s clients and will represent the “face” of the practice.

Customer Service Standards

It’s imperative that the medical billing company adhere to the highest customer service standards and represent the clinic appropriately.

Ultimately, practice owners must decide if the cost of outsourcing their billing and collection needs outweighs the expenditures of maintaining an in-house billing department. Therapists with an in-house system should examine their practice to ascertain the efficiency of the clinic’s system. If costs are high and collections are low, hiring a medical billing company may be in the practice’s best interests.

How to Verify if Your Software is ICD-10 Ready

How to Verify if Your Software is ICD-10 Ready

The big day for the ICD-10 transition is just around the corner. Practices should have been using their time to train, install hardware and test their software for compatibility with other entities with which they communicate. However, despite the best laid plans and intentions, clinicians may not be as ready as they think. Software systems are a prime consideration and there are steps that practitioners can take to ensure they’re ready when Oct. 1, 2014 arrives.


There are dozens of EMRs available. They have multiple features, but clinicians are often required to pay extra for access to updates and other items that should be included automatically. Practitioners will want to ensure they have an EMR capable of handling the new codes and that they have the latest version available installed.

EMRs must have sufficient security measures for HIPAA compliance to safeguard patient information. Consult with vendors to verify that the EMR is HIPAA compliant, code upgrades are covered in any contracts, and if training will be included.


A crosswalk offers a means of translating ICD-9 codes to the new ICD-10 version. It’s essential that any software include those crosswalks for translation, especially in the early months of the transition. If the EMR doesn’t support crosswalks, clinicians may need to invest in a program to assist with coding tasks.


General Equivalence Mapping isn’t designed for long-term use, but it does provide a valuable resource. It’s a tool that can be used to assist in locating the correct code options and help staff become more fluent and comfortable with the new code selections.

Side-By-Side Coding

Until everyone in the practice is familiar with the new coding system, a side-by-side coding feature will prove very helpful. It will reduce staff frustration and help everyone rest easy knowing they’ve entered the correct diagnosis codes.

A system that allows clinicians and staff to incorporate the new coding into their everyday duties will help everyone become familiar with the new codes before the deadline. They can also begin using the new codes prior to the implementation date with entities that are ready.


It’s critical that in-house or contracted billing services are prepared for ICD-10. They must be compliant with the new HIPAA transaction standards for transmitting data electronically. Be prepared for a reduction in productivity, even with superior billers and coders.


Testing should include the ability to submit claims and insurance eligibility. The only way to ensure if a practice’s software is ready for the ICD-10 transition is to conduct exhaustive testing in those areas – then test some more. If any glitches or issues do exist, the more the system is used the more likely they will be to become apparent. It’s also important that inter-office systems can communicate with each other.

The software that transmitted a claim perfectly today has the potential not to work smoothly tomorrow. Continued testing is the only way to ensure that problems are identified and addressed prior to the deadline. If for some reason an issue can’t be fixed by implementation day, be sure to have a contingency plan. Relationships with new vendors may have to be established, so be prepared.

Significant coding changes will take place with implementation, but if the practice’s software can’t communicate successfully with insurance companies and clearinghouses to submit claims, they’re of no use and will cost clinics dearly in revenues.  Implementation is more than just a coding change. It affects every department. Ensuring the clinic’s software is working correctly will make the transition easier while maintaining revenue levels.

Almost everyone in the medical profession anticipate a loss of income with the implementation of ICD-10. However, some healthcare management and technology firms have postulated that the switch to ICD-10 will present practitioners with opportunities to increase revenues, as it will be easier to document co-morbidities. They also note that the key to increased revenues depends on greater documentation accuracy, one of the stated goals of ICD-implementation.

The Impact of ICD-10 on Billing Staff

The Impact of ICD-10 on Billing Staff

One of the areas that will be most impacted by the switch to ICD-10 will be the billing department. The ability of billing and coding staff to keep up with the increased coding requirements will have a direct impact on the continued flow of revenues to practices. Staff will need sufficient training in the new codes and even then, it may be necessary to engage additional personnel to address back logs.

After the deadline, any claims that aren’t submitted using ICD-10 will automatically be denied. Coding and billing staff will need the highest level of training available. People learn by doing and whenever possible, it’s a good idea to start using dual coding.

Practitioners that have their billing done by a professional agency will need to consult with the company to ensure the firm is prepared and revenues won’t be disrupted. Part of biller/coder readiness is ensuring that they and the software used is compliant with the strict HIPAA standards governing the electronic transmission of patient data.

Billers and coders may also need a refresher course in anatomy and physiology. The increased specificity of ICD-10 will require more in-depth coding. Billers/coders will find themselves using more specific terms than they’re normally accustomed. Next to the clinician, billers/coders are the most important link in the revenue chain. They must be ready for the transition or revenues will falter.,

Some interruption in the revenue flow will be inevitable. By its very composition, the new alpha-numeric coding system requires billers/coders to switch between a numeric pad and a keyboard, which will result in a slowing of coding claims. Super bills may no longer be a feasible option, requiring billers and coders to learn new forms and formats.

There are bound to be claims that are rejected in error due to the new coding. Claims will require resubmission and coders/billers will find themselves investing a significant amount of time communicating with clearinghouses and payers to determine why claims were denied. No matter how well trained the biller/coder is, those type of instances will slow down the submission and collection management process.

Errors in documentation and rejected claims will result in many patients receiving bills they don’t deserve. While it doesn’t directly affect billers/coders, it will have an impact on practices. Clinicians will see an increase in calls from panicked patients, requiring time and a cool head to explain and sooth clients.

Clinicians must adhere to coding guidelines if billers are to submit accurate claims. Practitioners can’t code for a suspected or probable diagnosis; items that would appear in notes must now be coded; coding should be done at the highest level possible; and a focus should be on medical necessity.

Clinicians and billers/coders have always had a partnership in terms of revenues and that relationship will be even more important as ICD-10 goes into effect. The billing department should be encouraged to seek verification and understanding of any item for which they’re unsure and clinicians should make time for this.

No one can hide from ICD-10. How each team member responds to its challenges will define the ultimate success of the practice and revenue flow.

The Funniest ICD-10 Codes

The Funniest ICD-10 Codes

Patients can be struck by numerous objects leading to pain, disability, physical therapy, and perhaps embarrassment, if the new
ICD-10 codes an accurate indicator. Some of the codes seem nonsensical or unlikely. The fact that the codes exist amply demonstrate that these incidences have occurred – and multiple times in some cases.

There’s an extensive array of items that can be thrown, tossed and dropped that will cause injury. Most will lead to a visit to the ER or the physical therapist. Clinicians will definitely want to be ready for patients who have been hit by rowdy wildlife, from dive bombing macaws (W61.12XA) to head butting cows (W55.22XA) who may object to being milked.

If Grandma gets hit by a reindeer, code it as a V06.00xA, but for individuals who get thrown from a sleigh pulled by reindeer, that’s a code V80.929A. People interacting with churlish chickens with a propensity for throwing themselves at bipeds will code as a W6a.32XA. The codes make no differentiation between rubber chickens and real chickens, but there are codes for multiple encounters.

Land animals aren’t the exclusive cause of injuries. For the luckless patients who experience injury at the fins of water-dwelling creatures, it may feel like a script for a disaster movie. Clinicians will find coding options for clients with first and subsequent encounters with outraged orcas (W56.22xA), those who have been exposed to turtles (W59.29) and not-so-playful dolphins (W56.02XA).

Some individuals are just unable to multi-task while doing even the simplest things. Distracted talking and texting has led to multiple mishaps that practitioners will be coding for and may lead to some strange encounters with payers. There’s a code for people running into a lamppost (subsequent encounter, W22.02XD) and when walking the family canine (W54.1XXA).

Mankind is adept at conceiving new ways of having fun and doing it in the most dangerous venues possible. Bungee jumping (Y93.34), parasailing (Y93.19) and even playing a percussion instrument (Y93.32) or Y93.J4 for lips stuck to an instrument, can lead to unwanted conclusions. A friendly game of ultimate Frisbee (Y93.74) is cited as the reason for pulled muscles, broken bones and even whiplash.

Even fun with imaginary and inanimate creatures can be hazardous. Individuals who sustain an injury by running through a snowman, (thereby committing snowman homicide or possibly a hit and run) will code as Y02.8xxA. For those who are confused about where to put the carrot during a snowman build and insert it in their own ear, use code T16.2xxA. On the dark side, those bitten by a vampire (superficial bite of other specified part of neck, initial encounter), that’s a code S10.87xA.

When hair causes constriction (initial encounter) clinicians will turn to code W49.01XA and E928.4 for an external hair constriction. For a non-scarring hair loss, there’s code L65.9. There’s no telling when a bad hair day will result in serious injury.

Even the very air is fraught with potential danger. For clients who discover they have an air leak, use code J93.82. Patients may be injured through falling spacecraft (V95.49XA). When clients displace their balloon, code it as a T82.523S, but for victims of a falling alligator, that’s code W5803XA.

ICD-10 codes reflect real incidents and complaints, but the ways in which they’re worded often make them fodder for fun. The primary points clinicians need to remember is that they need to code to the highest level possible and as accurately as possible – even if it results in long conversations with payers who have disbelieving minds. Perhaps they could code for a therapeutic massage.