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 21st 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.
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.
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.
Every entrepreneur dreams of launching a successful business, but many are at a loss once the goal has been achieved. Medical insurance billers (MIBs) may be tempted to rest on their laurels once they’ve made it to the “big leagues”. In this revealing article, Nitin Chhoda provides medical insurance billers with helpful advice when they’ve outgrown their home-based business.
It’s easy to let day-to-day operations slide a little in the excitement and chaos of moving to an outside office.
Joining the ranks of highly visible businesses means medical insurance billers will need to work twice as hard and employ every tool at their disposal to attract and retain new clients.
Location Isn’t Everything, But It Helps
It’s tempting to rent office space in a highly visible venue, but it may not be the best solution for the budget. Discount pricing doesn’t necessarily mean a low-rent district. It’s possible to strike an equitable deal for space in under-utilized structures.
Many business owners are choosing to rent a home to house their enterprise. It can offer a cost effective solution that provides a user friendlier atmosphere. Medical insurance billers that take this route should check local laws and ordinances to confirm they can legally conduct business from the location before committing to a specific property.
The face a business displays to the public has a significant impact on clientele. Potential clients that see a structured and organized office will perceive the business as professional and the medical insurance billers as someone who are efficient and get results.
Accommodate the Customer
Business expansion dictates that the MIB assume new clients and that may necessitate moving out of their comfort zone to land new accounts. They may be asked to provide services not currently offered. Medical insurance billers should always be willing to learn new things and do whatever is necessary to accommodate clients.
Medical insurance billers should endeavor to provide the customer with what they want, as long as they have the appropriate professional skills and knowledge to do so.
Growth and Expansion
Medical insurance billers typically move out of their homes and into the public domain when their customer base will support it. Beware of rapid expansion and acquiring too many new clients. The result is an MIB that feels overwhelmed, with the inability to provide each client with the personal attention they deserve. An over-abundance of work entails hiring additional staff that may require significant training.
Be realistic when planning goals and anticipating revenues. Always expect the unexpected, from replacing equipment and hiring staff to unforeseen accidents. Medical insurance billers may need to increase their rates, but use caution or run the risk of losing even established clients. Think quality, not quantity.
The Little People
Being charming, gracious and accommodating is easy when physical therapy billing business owners are seeking their first clients.
The same rules apply when medical insurance billers are at the helm of a growing enterprise. No business owner should ever forget the individuals, clients and subsequent referrals that helped them reach their current level of success.
Medical insurance billing encompasses much more than entering numbers in a pre-made form. Medical insurance billers (MIBs) must have a strong working knowledge in a variety of fields and understand the many terms they’ll encounter.
Whether MIBs choose to work in a medical facility or launch a home-based business, they’ll find it extremely difficult to find employment or clients if they’re not familiar with the terms of the trade. Nitin Chhoda discusses more.
Medical Terms and Codes
CPT and ICD-10 codes are the method MIBs use to describe to insurance companies the diagnosis and treatment that each patient received.
Most healthcare providers only use a fraction of the thousands of available codes, but MIBs must be familiar with the lexicons used by their clients.
Billing software or electronic medical record (EMR) technology is an essential. It’s capable of handling all the coding needs and tasks MIBs will require.
Insurance coverage is available as an individual policy (purchased by individuals) group (provided by employers) and government programs (Medicare, Medicaid, CHIP, CHAMPUS VA, TRICARE and Workers’ Compensation). Each will have its own set of rules dictating what type of services and procedures are covered. Terms to know include:
Beneficiary – who is eligible for services;
The insured – the primary person who has the policy, making it possible for his/her dependents to receive services;
Dependents – a spouse or children;
Co-pays and deductibles – costs paid by patients as individuals or as a family;
Provider – healthcare professionals, from those who treat clients to facilities that provide medical supplies;
Exclusions – services, procedures and treatments that are not covered;
Pre-existing condition – a medical condition that existed before the policy took effect;
Maximums – the maximum amount an insurance company will pay within a year or lifetime;
Pre-approval – services or treatments that must be approved by the payer prior to receiving them;
Co-insurance – a second policy that provides medical coverage and shares the cost of an individual’s costs.
Payers and Clearinghouses
Clearinghouses use EMR software to receive reimbursement claims and forward them on to insurance companies for payment. Insurance companies (payers) have a language all their own that’s employed when dealing with practitioners and medical billing professionals. Common terms include:
Usual fee – the cost doctors charge for specific services;
Customary fees – are based on 90 percent of fees charged within a geographic location;
Reasonable fees – is the lesser of what the doctor bills, usual fees, customary fees or a special fee that must be justified;
Provider network – is a network of medical providers and facilities that beneficiaries are allowed to see that are covered under their insurance policy.
Numerous educational and certification resources are offered by professional MIB organizations to assist individuals in learning the lingo of the medical insurance billing field. Individuals can find informative books at the library, subscribing to online MIB lists and forums and asking questions, and gain experience through mentoring.
An MIB who can talk the talk with providers and payers will find multiple avenues in which to demonstrate their acumen.
If you are not using an EMR system already, then the time to consider it is now. That’s not all. You want to ask the important question “Is my EMR system recognized and tested by the Office of the National Co-ordinator (ONC) and how can I verify this?”.
Healthcare is changing and practitioners must transform their practices to remain in business.
Government Sanctioned EMR Technology
We’re living in a new world, and I call it the “Obamacare Economy”. As a clinician, it’s your responsibility to document, code and bill effectively, and make sure everything is reported to CMS and other payers. You can achieve this the hard way with pen and paper, or the easy way with EMR technology.
Even through physical therapists are not ‘eligible professionals’ and therefore not eligible for Meaningful Use incentives like physicians, physical therapists should consider using (at minimum), a base EHR certified technology from January 1, 2014 to be eligible for PQRS incentives, according to a CMS Rule published 11/16/2012 that can be found here:
“Therefore, based on the comments received, we are also finalizing to the requirement that a direct EHR product be certified by ONC as Certified EHR Technology (CEHRT), and therefore meet the definition of CEHRT in ONC’s regulations (see 45 CFR 170.102), to submit PQRS measures. (For the 2014 Edition EHR certification criteria, please refer to 77 FR 54163)”
“We are discontinuing the qualification process and requiring that a direct EHR product be CEHRT beginning in 2014. A certified quality reporting module may be part of CEHRT, but CEHRT as a whole is more comprehensive. Please refer to ONC’s standards and certification criteria final rule for additional information on requirements for CEHRT (77 FR 54163).”
A CEHRT is defined as “EHR technology certified to the 2014 Edition EHR certification criteria that meets the Base EHR definition and would support the objectives, measures, and their ability to successfully report the CQMs, for the MU stage that they seek to achieve.”
These are the minimum modules that an EMR must be certified in to meet the requirements of being a CEHRT and being able to directly submit PQRS in 2014.
Includes patient demographic and clinical health information, such as medical history and problem lists
Demographics § 170.314(a)(3)
Problem List § 170.314(a)(5)
Medication List § 170.314(a)(6)
Medication Allergy List § 170.314(a)(7)
Has the capacity to provide clinical decision support
Clinical Decision Support § 170.314(a)(8)
Has the capacity to support physician order entry
Computerized Provider Order Entry § 170.314(a)(1)
Has the capacity to capture and query information relevant to health care quality
Clinical Quality Measures § 170.314(c)(1) through (3)
Has the capacity to exchange electronic health information with, and integrate such information from other sources
Transitions of Care § 170.314(b)(1) and (2)
Data Portability § 170.314(b)(7)
Has the capacity to protect the confidentiality, integrity, and availability of health information stored and exchanged
Privacy and Security § 170.314(d)(1) through (8)
The EMR software you use must satisfy these criteria, and must be tested and accredited by one of the four bodies approved by the ONC.
ONC Certified Base EHR Technology – Is Your Vendor Certified by one of the ‘Big Four’?
The Office of the National Coordinator for Health Information Technology is responsible for certifying electronic medical records software, and it does so through FOUR ‘Certification Bodies and Testing Laboratories’, which play a key role in the ONC HIT Certification Program.
Certifying and testing Electronic Health Record (EHR) technology provides assurance to providers and other purchasers that an EHR system offers the necessary technological capability, functionality, and security to help them meet the Meaningful Use criteria, and helps maintain quality and consistency across the certified products. Once again, physical therapists are not eligible for Meaningful Use funds, but a minimum ‘base EHR’ technology is required for reporting PQRS measures.
In the ONC HIT Certification Program, ONC-Authorized Certification Bodies (ONC-ACBs) conduct certification and Accredited Testing Laboratories (ATLs) conduct testing.
A single organization can be both an ONC-ACB and an ATL. ONC has authorized the following certification bodies to serve as ONC-ACBs in the ONC HIT Certification Program:
Certification Commission for Health Information Technology (CCHIT)
InfoGard Laboratories, Inc
Only test tools and test procedures that have been approved by the National Coordinator can be used to test Complete EHRs and/or EHR Modules in order for them to be eligible for certification by an ONC-Authorized Certification Body (ONC-ACB). ATLs are authorized to test Complete EHRs and/or EHR Modules according to the 2011 and/or the 2014 Edition EHR Certification Criteria.
The test tools and test procedures that align with the 2014 Edition are available here
On this site, providers can access all certified software and select individual products or combinations of products to use to attest for Meaningful Use funds through the CMS. Providers can also look for EHR vendors that have been tested and certified for certain specific criteria (these will appear as ‘Modular EHR’ technologies).
Try it out by selecting a 2011 or 2014 Edition software, placing it in the shopping cart, and see the resulting message that is generated.
What this Means for Physical Therapy Private Practice Owners
Physical therapists who bill Medicare must report PQRS measures (and Functional Limitation G codes) to avoid penalties and the best way to do this is with the use of an EMR system. Your EMR should be a registry, or provide claims based reporting options to CMS, or better yet, be recognized by the ONC as a ‘Modular EHR’ that fulfills the requirements of a ‘base EHR’.
Technology like this offers the ability to collect reimbursements quicker, maintain security compliance, and increase the profitability of practices.
EMR systems contain functionality to track multiple variables that affect the practice and market services successfully. The software can be deployed on tablet technology for portability, allowing therapists to save time during the patient encounter and complete paperwork electronically for quicker billing turnaround.
The EMR technology of the future must help grow your practice. It’s not enough for an EMR vendor to be ‘just another vendor’ that sells you software for scheduling, documentation, compliance and billing. It’s not enough for the software to have perks like appointment reminders and home exercise programs.
Your practice needs way more than that to be able to help you grow in the Obamacare economy, and that’s why we built In Touch EMR.
Your EMR software has to go above and beyond what it’s doing now.
It has to help you increase profits by integrating all the following within the interphase of the EMR software:
Increase referrals from physicians with automated marketing systems
Increase referrals from patients with automated newsletters, greeting card, phone, text and email communication systems
Increase referrals from other business in the community by creating and automating cross promotion marketing campaigns
Converting prospects to patients with done-for-you educational resources automatically distributed to patients
Diversification – The Way to Thrive in this New Economy
In this new economy, you don’t want to ‘keep all your eggs in the Medicare basket’. As patients see a decline in the quality of physical therapy, they will be looking for (and willing to pay for) options that make them healthier.
This is an unprecedented new opportunity, unlike anything we’ve ever seen before in physical therapy private practice.
That’s exactly where you come in.
Today’s patient is eager to partake of services and products perceived as “luxury” items. Known as cash paying services, they’re paid for at the time they’re delivered. Options include selling supplements, durable medical supplies and medical products to better serve patients and create multiple income streams.
Hiring the right staff to provide the services, and the right systems to be able to track these services is the first step towards diversification. Speaking of systems, nothing is more important than a simple, yet powerful electronic medical records (EMR) system for your private practice.
With the portability of EMRs, practitioners can expand their repertoire of offerings at the clinic and in other venues. Clinicians can feature a variety of different massage therapies, weight loss clinics and nutritional information, along with personal training,acupressure and wellness programs. Aquatic therapy, women’s programs, athletic training services and fall prevention offerings are also popular.
Your Action Plan with Obamacare
Strategies to maximize Medicare payments include:
Be more efficient with time spent with all patients, especially Medicare
Be more knowledgeable about the types of CPT codes and number of units billed
Here is how you can maintain (and even increase income) in the Obamacare economy:
Diversify your payer mix by having payers other than Medicare, preferably those who pay more than Medicare. Look at your payor contracts to determine how much you are getting paid and identify the ones where you are paid more. Reduce your dependence on Medicare patients. We can help you analyze this, as part of our coaching service in the Referral Ignition Elite program.
Setup different cash paying programs to increase income and increase lifetime value of each patient. Mobilize your staff, patients and referral sources to help you increase referrals and grow the practice. Diversify sources of income and services to serve patients better to make your business multi-faceted and diverse. You can get several free tips and tricks on how to market your private practice at our blog.
Clinicians must be more efficient in the time they spend with patients, from ascertaining the source of their ailments and creating documentation to preparing claims for billers.
Besides the clinician, the biller is the most important person in the practice. Here are some of the most time consuming aspects of billing:
Creating claims by copy pasting ICD, CPT, modifiers, supporting diagnosis data into the billing software
Editing and scrubbing this data before it is submitted to the payer
Manually batching claims and uploading them to the clearing house
Manually reviewing and posting ERAs to the patient record
Submitting secondary claims
Generating and mailing patient statements
Here’s the good news – EMR systems such as the In Touch EMR and the fully integrated In Touch Biller Pro automate all of these tasks for the biller. This allows the biller to focus on the things that drive revenue for the private practice such as:
Make sure all claims are submitted as quickly as possible
Identify reasons for denials and eliminate them
Provide simple guidelines to clinicians to maximize reimbursement and minimize denials
Call the insurance companies to follow up on claims
Make sure all EOBs are entered promptly
Write and mail appeal letters
Follow up with patients to make sure statements are paid
This makes things easier for the private practice owner, allowing him or her to plan and implement diversification endeavors.
Concierge Services – A Bold New Alternative
Concierge practices, also known as direct pay practices, are typically the bastion of primary care physicians, but the concept can work for physical therapists. In a concierge practice, patients pay a monthly or annual fee for enhanced services that can include same day appointments, email consultations, extended patient encounters and 24/7 access to their therapist, along with other perks.
Practitioners generally maintain a smaller roster of clients, but are paid better and work fewer hours. It’s a healthcare option that enables clinicians to practice in their own way, reduces staffing, compliance and administrative costs, and treats patients as individuals rather than part of an assembly line. Therapists can also continue to accept insurance payments if they choose.
Therapists don’t want to turn away any patient, especially those with Medicare who may need them most, even though they’re underpaid through Obamacare.
To combat the negative impact of Obamacare on patients and practitioners, clinicians must increase the efficiency level during the patient encounter.
Identifying cash paying services and products appropriate for the practice allows clinicians to attract a larger and more diverse clientele. Those services and products will establish multiple streams of revenue that ensures profitability through any economy and helps practices survive Obamacare.
Medical billing is experiencing unprecedented growth compared to other professions. A variety of misconceptions and unrealistic expectations have accompanied that development.
In this revealing article, physical therapist and electronic medical record (EMR) specialist, Nitin Chhoda, examines the misconceptions associated with a medical insurance billing business.
As the demand for medical insurance billers (MIBs) has grown, so has the number of scams promising individuals enormous incomes with no experience needed.
Despite advertisements to be found in multiple media outlets, there is no such thing as a home-based biller.
No medical provider will allow sensitive information to leave the office for someone to toil over like medical billing homework. While there aren’t home-based billers, there are medical insurance businesses that are operated from the biller’s home.
Despite claims to the contrary, a career in medical billing requires specific skills. MIBs must demonstrate a level of competence to become certified that requires a myriad of specialized knowledge. Would-be billers can’t learn as they go and should seek appropriate educational venues.
MIBs will need a working knowledge of ICD-10 and CPT codes, anatomy, clearinghouses, and both commercial and government-funded insurance programs.
Short Hours, Big Pay
Medical billing isn’t a way to get rich quick. Don’t expect to make $40 an hour or $50,000 in the first year. Those claims are the tools used by scammers. MIBs typically make $11-$20 an hour, depending on their level of experience. Entrepreneurs should be aware that the company may not make a profit in the first year, or even the second.
Launching a new business is time consuming. Operating a business from home provides individuals with the flexibility to set their own hours, but shepherding a new business to success is time consuming. Fledgling business owners should be prepared to put in a lot of long hours. Medical billing is a year-round job.
Certified medical billing people that choose to go into business for themselves are responsible for every facet of their enterprise and they must be self-starters. There will be no supervisor watching a time clock or conferring assignments. Working at home is convenient, but it can also be distracting. MIBs will need to be organized and learn to manage their time wisely.
More than Numbers
MIBs do more than just type numbers in a form on a computer. They verify information, check for appropriate coding and transmit reimbursement claims.
Medical billing staff also monitors claims that have been paid and those that haven’t, along with posting payments to client accounts and providing friendly reminders for patients with balances due.
Billers shouldn’t expect to sit home alone with their computers. They have to interact with others in person and via phone.
Medical insurance billing is one of the fastest growing career opportunities available and unscrupulous individuals have taken advantage of that to sell impossible dreams and expectations. Anyone who wants to launch a medical billing firm should begin with the necessary education and be willing to put in long hours to grow a respected and reputable business.
Denials disrupt a medical insurance biller’s (MIB) cash flow to their clients, but incurring exclusions from one of the government operated healthcare programs can cost thousands of dollars. Exclusions severely limit employment opportunities and in this revealing article, Nitin Chhoda examines exclusionary factors and what it means for billers.
Any individual or entity that works with government healthcare plans can be excluded from the network, from hospitals and clinicians to billers.
There’s an extensive number of ways that billers can garner exclusions. The good news is that there are preventative measures that billers can take to protect themselves and their clients.
Keeping current on coding is essential for obtaining reimbursements and it helps MIBs avoid claim denials. CPT codes are updated annually and those using old, obsolete or defunct codes run the risk of having a claim reimbursed at a lower level.
At the payer’s discretion, the carrier may refuse to recognize the claim at all. When billers obtain a new client, it’s a good idea to take a look at their coding and forms to ensure they’re using the most current codes.
ICD-10 codes will soon replace the old system and updating to the new codes is critical for claims to be accepted. Healthcare practice management insurance carriers will reject and deny any claim that doesn’t employ the new coding system.
Current coding allows practitioners to be reimbursed at the highest level and provides proof to carriers that the charges are justified.
Attending seminars and conferences is a good way to stay up-to- date on the latest trends, laws and practices that relate to the billing industry. Many carriers provide free seminars and professional billing associations offer online webinars and resources. Subscribing to newsletters and bulletins from professional organizations is also a good source of knowledge.
Exclusions and Causes
There are two types of exclusions – permissive and mandatory – and they’re governed by the U.S. Office of the Inspector General (OIG). Depending upon the offense, those who have incurred exclusions will find their employment opportunities curtailed and they can even lose their license. Penalties are typically in effect for a minimum of five years. Mandatory offenses that require exclusions are:
Conviction of patient abuse or neglect;
Conviction of a program-related crime;
Felony conviction relating to healthcare fraud;
Felony conviction of a controlled substance.
Penalties for permissive exclusions vary from case to case, but are in effect for a specified amount of time set by the OIG. Permissive offenses that are at the OIG’s discretion include:
Failure to provide quality care;
Failure to repay college education loans;
Some misdemeanor convictions;
Lying on an enrollment application;
Loss of state license to practice.
Billing with the latest codes facilitates claims that aren’t denied, while ensuring prompt payments and uninterrupted cash flow for clients.
MIBs that garner exclusions will be unable to work or contract with facilities or clinicians that participate in government healthcare programs, and will lose income should one of their clients incur exclusions.