Services Rendered: The Options to Offer as a Medical Insurance Billers

Services Rendered: The Options to Offer as a Medical Insurance Billers

The future of medical billing is as bright and busy as billers want to make it. As various portions of the Affordable Health Care Act take effect, professionals and health care facilities will be serving an influx of new patients, requiring a variety of billing related services.

In this informative article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines services offered by medical insurance billers (MIB).

medical insurance billersCertified medical insurance billers provide a variety of services, from coding and transmitting reimbursement claims to accounting and tracking accounts, along with full practice management services.

Much depends upon the work environment. Those who work in medical practices and facilities may be tasked with simply coding and transmitting claims electronically.

Medical insurance billers working from home may choose to offer a la carte services to meet the specific needs of the client. Tracking accounts receivable and payable, and pursuing unpaid amounts owed by insurance companies and individuals are also part of a biller’s duties.

Who Are The Clients?

Most medical insurance billers think exclusively of medical practices when offering services, but any healthcare provider or facility is a potential client, from small clinics to practices with multiple clinicians. Hospitals, nursing homes and mental health professionals offer other options. Often overlooked sources of clients include dentists, pharmacies and social workers. Services can be adapted to meet individual requirements.

Customized Services and Specialties

Certified medical insurance billers always seek to bill accurately and quickly to increase the cash flow for their clients. They may also take on a multitude of other duties, including making referrals and recommendations within the field. Some medical insurance billers have taken their prior experience in marketing and other professions and applied it to billing to assist practitioners promote their products and services.

Medical insurance billers have their finger on the financial pulse of practices. They can determine when a client’s finances are faltering and offer consulting services. Some medical insurance billers specialize in services to physicians just starting out who can’t afford an in-house biller, as well as medical professionals who are closing out their practice.

Others have found their niche by working with rural providers who don’t have access to medical billing services or by handling non-insured patients.

EMRs and Portability

EMRs are an essential element for medical insurance billers, allowing them to perform their tasks quickly and efficiently, with clean claims that approved the first time. Built-in functionalities meet HIPAA security standards and EMRs provide alerts if claims contain potential problems or if a security issue is present. medical insurance billers with EMR

An EMR also provides medical insurance billers with portability, allowing them to offer services from multiple locations and take the job to the client.

The software systems are capable of producing graphs, reports and charts to keep practitioners informed of how they fare financially.

Multiple opportunities exist for medical insurance billers and those who are willing to offer specialized, customized services are indispensable. Billers who offer the little “extras” are in high demand, but medical insurance billers should never lose sight of their most important goal – quick and accurate billing that produces a steady monetary flow for clients.

Understanding the RAC Audit Process

Understanding the RAC Audit Process

One of the greatest challenges facing practitioners is a potential investigation by a Medicare Recovery Audit Contractor (RAC). Medicare estimates that there is a sixty two percent error rate among reimbursement claims in which documentation doesn’t match the billed expenses.

Private practice marketing expert, Nitin Chhoda, says that when services, fees and documentation don’t match, it increases the possibility of a RAC audit. The good news is that there are concrete steps clinicians can take to reduce the risk. And he shares that information in this article.

RACEven with the best coders and billers, errors can occur and it’s ultimately the responsibility of the practitioner to ensure that records match.

Knowing how the RAC process works allows clinicians to develop measures and install appropriate software systems to minimize risk factors that lead to an audit.

Medicare RAC auditors examine reimbursement claims after payment has been made, using methods similar to those employed by commercial healthcare insurance carriers.

The practice is known as pay and chase among industry officials. They look for inconsistencies in the billable services and submitted documentation.

RAC auditors utilize methods that comply with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.

Determining the Two types of Audits

There are two types of audits – automatic and complex.

  • An automatic audit seeks easily identifiable errors in payments, but doesn’t require human intervention or medical records to determine a problem exists.
  • A complex audit addresses improper payments through a manual evaluation and a request for extensive supporting documentation. Medical providers have strict and definite timelines in which to request an extension, comply with producing the appropriate records, and make appeals.

The process doesn’t stop there. Practitioners singled out for a RAC will be reported to CMS for potential fraud. If the RAC determines the problem is a potential quality issue, they report the provider to the state’s Quality Improvement Organization.

Initiate Self-Audits in order to Minimize RAC Interventions

Conducting self-audits will help minimize RAC interventions, but the best way clinicians have of avoiding an audit is to ensure their flow sheet, plan of care and billed expenses all match. If they don’t, it’s a problem and the responsibility of the practitioner.

Integrated electronic medical record (EMR) software is a critical element and provides the first line of defense toward that goal of avoiding an audit.

RAC auditorsEach EMR differs slightly, but systems such as the In Touch EMR, and In Touch Biller Pro, have capabilities specifically designed to assist coders and billers.

When data is entered, it prompts and advises the user for information and data to ensure all the components match and support each other.

It’s a crucial feature that offers a greater level of compliance and minimizes the probability of an audit.

Knowing how and why a RAC audit is conducted provides clinicians with the necessary information to help them avoid the experience. Confirming that the flow sheet, plan of treatment and documentation are all in agreement is the first step. The second is implementation of an “intelligent” integrated EMR physical therapy software system.

An audit isn’t desirable, but instead of living in dread practitioners should look upon a RAC audit as an additional way to maintain compliance.

What Lies Ahead With Medicare Payments?

What Lies Ahead With Medicare Payments?

The Affordable Health Care Act changed the healthcare landscape and it’s evolving further through new Medicare decisions. The only way for practitioners to financially survive the uncertainty is through diversification. To help practitioners prepare for the future, Nitin Chhoda addressed Medicare payments and diversification.

MedicareIn a forced Medicare economy, clinicians need to diversify their practice to prepare for the loss of income that will come through the Affordable Health Care Act and the reduction in Medicare payments.

Practitioners need to implement cash paying services they can add to create additional revenue streams.

What Statistics Say …

Multiple payment reduction (PPR) now places limitations on payments. Medicare currently pays seventy five percent for PPR visits and it applies to clinicians in single or group practices.

Clinicians have seen a six percent reduction in payments on the low end and twenty percent on the high end.

Physicians have already seen the impact in the physician quality reporting system (PQRS). So far in 2013, practitioners have seen the incentive program go from voluntary participation to one that will be mandatory for eligible providers in 2015. Payments in PQRS are steadily being reduced.

Beginning in 2015, the program assesses penalties for providers that are “poor” reporters.

Many providers are concerned that Medicare could theoretically use PQRS data collected at eighty nine locations throughout the nation to set payments by geographical area. Apprehension also exists that Medicare might establish caps on the number of visits a patient can have to be considered “well.”

So What Are We Going to Do?

Will we be looking at patients as human beings or at the number of visits they’re allowed? Do we discharge them even if they’re not well because we won’t get paid?

Medicare may never increase – do we drop these patients? I would hope not, but I believe we’ll see commercial carriers doing the same things as Medicare.

The solution is a two-step process. Clinicians must be more efficient in the time they spend with patients, the types of codes they use, and the units billed when dealing with Medicare. An EMR is essential to plan, implement and market diversification efforts.

Systems such as In Touch EMR and In Touch Biller Pro, contain the functionalities needed to handle the undertaking, along with sophisticated training and strategies.

Diversify Payments and Create Cash-Paying Programs

Practitioners must also identify cash paying programs to make up for the loss in revenues. They can add the following to their practice:

  • Medicare coverageCash paying services such as products and services paid at the time they are received.
  • Accepting payments through cash, checks, debit and credit cards.
  • Selling supplements, medical products and durable medical supplies to serve the patient better.
  • Other cash paying options include weight loss clinics, massage therapy and personal training.
  • Diversifying into multi-faceted practices with alternative medicine, nutritional information, aquatic therapy, acupressure and corporate wellness programs.

Electronic medical records provide mobility for increased opportunities.

Changes in Medicare, combined with the Affordable Health Care Act, are changing the way clinicians operate their practice. Faced with very real financial deficits in reimbursements, clinicians must utilize cash paying programs and use their time more efficiently to ensure Medicare patients receive care and practices continue to flourish.

Insurers and Doctors Decline Marketplace Policies

Insurers and Doctors Decline Marketplace Policies

One of the major selling points for the Affordable Health Care Act was the ability for patients to keep the doctors they liked and the coverage they had. Individuals without insurance can now sign up for an insurance policy at the Healthcare Insurance Marketplace, but there’s no guarantee a particular doctor will be a participant in their patient’s plan.

ObamacareSome insurance companies have changed or altered the criteria used for participating clinicians, a factor that’s led to the exclusion of many providers and facilities.

Many insurers have chosen not to participate in the Marketplace at all.

For patients, keeping the doctor with which they’ve built a relationship could mean purchasing a Marketplace policy they don’t want or losing their physician.

Controlling Costs and Profits

Insurers create their own networks of clinicians, specialists, hospitals and pharmacies with which they work to control costs.

If an individual’s current practitioner isn’t among the list of providers in the plan they purchase through the Marketplace, that patient will be forced to find a new primary care physician.

Medical professionals and facilities deemed as too expensive aren’t being included in the Marketplace plans by insurance companies. Much depends on the individual plan.

In California, Cedars-Sinai is one of the providers that aren’t covered in the state’s Marketplace policies.

Some of the insurance industry’s biggest players who offered Marketplace policies have since chosen not to participate in the Marketplace, even in states in which they already offer coverage.

That decision leaves patients with fewer plans and physicians from which to choose, and will critically impact those in rural areas.

Aetna, BlueCross, Cigna, Humana and United Health are just some of the providers that have announced they wouldn’t be participating in exchanges when a state’s regulators told them their rates were too high.

Insurers indicated the premiums they collected through the Marketplace would be insufficient to cover the cost of the services Obamacare requires them to provide.

Practitioner ProtestsObamacare

In many states, clinicians have begun turning away Medicare patients due to severe cuts in reimbursements and the practice is extending to patients with Marketplace policies.

In a study by the Medical Group Management Association, only 29 percent of the 47,500 respondents indicated they will accept Marketplace plans, citing new administrative and regulatory rules as the reason.

Eighty-five percent cited low reimbursement rates for Medicare and Marketplace plans as a reason for non-participation.

The number of insurance companies refusing to participate in the Marketplace and those limiting the providers in their network has the potential to reduce access to services ranging from primary care physicians and hospitals to labs, pharmacies and hospice care.

When purchasing a Marketplace policy, patients should make every effort to discover if their preferred practitioner is a participant in the plan. Unfortunately, provider directories are in short supply and locating the needed information can be a nightmare of website navigation.

Medical Billing Basics, Rules, and Regulations

Medical Billing Basics, Rules, and Regulations

A medical insurance billing (MIB) specialist is one of the most trusted individuals in a practice. Clinicians trust billers with the personal information of their patients, to obtain the largest revenues to which they’re entitled and to do so in a manner that’s accurate and legal. Nitin Chhoda discusses why integrity is one of the greatest assets a medical billing staff must have and why it should never be compromised.

medical billingCertified MIBs are specialists in their field and must conform to accepted coding practices and standards.

They have a moral, ethical and legal responsibility to code each reimbursement claim accurately, and deal fairly with patients, providers and payers.

Medical billing people are legally accountable for maintaining compliance and confidentiality, even if encouraged by unscrupulous individuals to “bend” the rules.

Ignorance is Never an Excuse

Coding regulations and requirements for submitting claims can change quickly. The onus is on the medical billing staff to remain informed and current, whether it’s a coding change or the manner in which clearinghouses accept reimbursement claims.

Always Keep it Private

Many billers are required to sign a confidentiality agreement and it’s becoming standard procedure in many practices. Confidentiality is more than a suggestion. It’s the law as outlined by HIPAA.

IMPORTANT: Patient information is to be protected at all times and there are stiff criminal penalties for those guilty of violations by word or deed.

Mistakes Cannot be Avoided But Should Never Be a Habit

No one is perfect and mistakes will occasionally be made. If there’s doubt about data contained in any portion of the patient encounter, obtain clarification from the practitioner before coding. When a medical billing staff makes a mistake, they’re obligated to report it to the payer and correct it.

No to Fraudulent Billing

There are many ways in which medical billing may be considered fraud. Over billing or unbundling to obtain more money, and under billing to get claims approved quicker, hurts the financial well-being of the practice and is illegal.

Routinely forgiving patient balances or failing to collect co-pays may run the practice afoul of anti-kickback statutes.

Insurance carriers are always seeking ways to avoid paying claims. Double billing and claiming for unnecessary procedures are red flags for payers, who have the option of initiating an investigation into the clinic and its medical billing practices.

Maintaining complete documentation that supports each medical billing reimbursement is critical.

Being Compliant is a Must

Medical billing staff must work within the dictates of the National Correct Coding Initiative edits to provide ethical, accurate and honest cost accountings to which practitioners are entitled. medical billing software

To maintain compliance, MIBs are charged with providing documentation that supports a diagnosis or procedure, and to explain costs that exceed the expected norm.

Compliance also extends to the methods by which patient information and reimbursement claims are transmitted.

The Affordable Health Care Act has mandated that billers and any entity or facility that transmits a patient’s personal data must do so through electronic medical record (EMR) technology that provides the appropriate security and safeguards.

As certified medical insurance billers, medical billing staff must have an ethical and legal responsibility to code correctly and accurately. They must maintain compliance within the confines of state and federal law, and be cognizant of the numerous requirements of insurance carriers.

Doing so will increase the number of clean claims that are paid promptly and ensure that the medical billing staff and practitioner’s reputations remain above reproach.

Medical Billers / Coders — How to Obtain Certification Part 2

Medical Billers / Coders — How to Obtain Certification Part 2

The American Academy of Professional Coders (AAPC) is one of the most respected and reputable medical billers / coders organizations in existence. The group is the primary certification, education and information resource for those entering the field of billing/coding. Nitin Chhoda explains more about the organization in this second part of two-part series of becoming a certified medical biller / coder.

medical billers / codersMedical billers or coders are knowledgeable in a variety of disciplines, from anatomy and medical terminology to specialized software systems and CPT and ICD codes.

Depending upon the level of certification desired, prerequisites can include completion of specific courses or a four-year degree before being sufficiently qualified to take a certification exam.

The AAPC provides education and professional certification for medical billers or coders employed within a practitioner’s office and hospital. It promotes the highest standard of coding through adherence to accepted standards.

NOTE:  The organization maintains strict eligibility requirements for full certification.

AAPC training programs are offered throughout the U.S. for those who will work in private practices and hospitals.

It offers continuing education opportunities, awards certifications, maintains a job database, and conducts regional and national conventions. Individuals have access to resources and materials essential to the profession, and learn about auditing, compliance and practice management.

Certified Professional Coder – the Entry Level

The AAPC offers entry level and apprentice level of medical billers or coders certifications. The basic certification is CPC (certified professional coder) and indicates the individual is proficient with procedural and supply codes, can extract correct diagnosis codes and read a medical chart.

Those with a CPC designation typically work in outpatient environments and will have a working knowledge of medical terminology and anatomy.

Certified Professional Coder-Hospital

A certified professional coder-hospital (CPC-H) demonstrates that the medical billers or coders understands compliance and can complete billing forms used for facility claims.

This level shows that the biller can accurately assign diagnosis, procedural and service codes in an outpatient environment, and use appropriate modifiers when necessary.

Certified Professional Coder-Payer Designation

The medical billers or coders holding a certified professional coder-payer designation (CPC-P) has exhibited a good working knowledge of the payer process. It demonstrates the individual is cognizant of the relationship between coding and payment, understands the adjudication process, and knows the coding-related payer process.

Those medical billers or coders who have completed two years or more of prior experience before taking and passing the exam will be fully certified. Individuals sitting for first time exams and those with no prior experience will receive apprentice status as CPC-A, CPC-H-A or CPC-P-A.

Test takers of medical billing and coding certifications must prove through a letter from their employer that they have prior experience and what their duties encompassed.

medical billers or codersThey must also provide documentation showing they’ve completed at least 80 hours of coding education and completed a year of on-the-job training using CPT, ICD and HCPCS codes.

Anyone can claim to be medical billers or coders, but credentialing provides proof from a respected and reputable professional organization that these medical billers or coders have achieved a superior level of accomplishment, and have attained the required level of knowledge and proficiency.

Certified medical billers or coders command a higher rate of pay and certification opens multiple career path opportunities. You can also check the first part of this two-part series on how to be certified medical biller or coder by clicking here.