The Life of a Claim: How You Get Paid

The Life of a Claim: How You Get Paid

The clock starts ticking on the life of an insurance claim the moment a patient makes an appointment and doesn’t end until the practitioner is paid. To better understand the life cycle of an insurance claim, Nitin Chhoda offers a first-hand look at the process.

claimFirst Contact
When clients contact a practice, it sets in motion a process in which it can take up to three months for the clinician to be paid.

Before patient arrives at the office, staff should already have obtained and verified the individual’s healthcare insurance information to ensure the policy is in force, hasn’t lapsed and who is covered, along with any limitations or restrictions.

Insurance benefits can be tricky to navigate. Clinicians must ascertain exactly what’s covered under the patient’s claim insurance, their deductible and co-pay when they make an appointment. It will impact the client’s available treatment options. Some individuals have coverage under more than one insurance provider. Both policies must undergo the same rigorous verification.

Patients will also be required to sign consent forms allowing the practitioner to bill the insurance company and be paid directly, release information for billing, and for the client to pay any amount not covered by insurance claim. A copy of the client’s identification and insurance card is required, along with a complete health and medical history.

Enter the EMR
All the client’s information must be entered in the practice’s EMR for medical billing. Incorrect or incomplete information will delay reimbursements to the clinic, as will failure to obtain an authorization for procedures. Insurance providers will deny a payment if the correct forms aren’t used, information is incomplete and for other breaches of the company’s particular set of rules.

To document the client’s visit, clinicians will create an encounter form that provides pertinent information about the patient’s complaint, exam, diagnosis and procedures performed. Any secondary problems that are observed must be documented and all the information entered into the EMR. Each diagnosis and procedure code must match or the claim will be denied.

Calculating Fees
Clinicians can now enter the cost of the visit utilizing their schedule of fees. Each procedure and all materials must be calculated into the final cost, from the use of the exam room to bandages. It’s also time for the patient to determine how they’ll pay for any portion of the cost for which they’re responsible.

That can take the form of cash, check, debit or credit cards, or a payment plan. Collect at least a portion of the payment before the client leaves the office.

Submitting the Claim
A reimbursement claim must be prepared and sent to the client’s insurance carrier, complete with documentation of the patient’s financial and clinical information from their visit. Each claim should be double checked to ensure that codes and patient information match, and that there are no omissions, or the claim will be delayed.

The claim will examined in extensive detail by the insurance company to ensure the client is covered, any restrictions and limitations were adhered to, accurate coding was included and information is complete. insurance claim

If a problem arises, the clinician will be asked for additional information or to resubmit the claim.

Practitioners can appeal the decision, collect any unpaid amount from the client or write off remaining costs.

It can take a typical claim up to three months to be reimbursed, even without any difficulties. Using an EMR ensures HIPAA compliance, protects against loss, decreases processing time and accelerates the entire process for quicker deposits and better cash flow.

Payer : Who Is It and Who Has the Money? Part 1

Payer : Who Is It and Who Has the Money? Part 1

Medical professionals collect reimbursement payments from a variety of sources. Known as payers, they encompass commercial insurance companies, third-party administrators and government-funded programs.

In part 1 of this revealing article, Nitin Chhoda identifies the major commercial payers and third-party administrators, and what clinicians need to know to obtain reimbursements.

payerA wealth of commercial insurance plans payer exists to help individuals pay for medical expenses. That includes preferred provider, point of service, health maintenance, and discount plans.

To ensure that services are paid for, practitioners must verify the client’s coverage each time they visit the office and ascertain any limitations as it will have a direct bearing on treatment options.

When contracting with a payer, it’s important for clinicians to know if the insurance company is the entity that actually sets the amount that medical professionals are reimbursed. Some participate in a payer network that determines how much practitioners are reimbursed for their services. Some networks pay better than others and clinicians should exercise due diligence in researching payers.

Commercial insurers
The most common form of insurance practitioners will encounter is the commercial policy, typically offered through the patient’s or spouse’s employer. This type of coverage will fall under one of the following:

•    PPO – A preferred provider network is a group of healthcare professionals and facilities that have agreed to provide services at reduced rates.
•    HMO – Health maintenance organizations rely on a network of healthcare providers, but clients are assigned a primary care physician and care must be accessed through that physician.
•    POS – Point of service coverage is a hybrid blend of a PPO and HMO payer. Patients who visit an HMO medical provider are covered under HMO benefits. If they see a PPO provider, they receive coverage through the PPO.

•    EPO – An exclusive payer or provider organization plan requires patients to select a primary care physician and obtain a referral before seeing a specialist.
•    High deductible plans – These offer patients low monthly premiums and deductibles that can begin at $4,000 or more.
•    Discount plans – These plans require patients to pay a monthly fee to obtain access to participating providers. They’re not true healthcare insurance plans.
•    COBRA – Coverage under a Consolidated Omnibus Budget Reconciliation Act plan is a payer that is dependent upon patients making their monthly payments on time. If a payment is late, claims will be rejected or the coverage cancelled.

A COBRA plan is interim coverage when an employee loses or leaves their job.

Third-party administrators
A third party administrator (TPA) or payer is the middleman of healthcare. TPAs are operated as an independent network, or price claims by accessing other networks.

They handle claims for employers who insure their own employees rather than participating in a commercial group program. medical payer

Reimbursement problems can arise for clinicians if the TPA prices the claim incorrectly or the claim isn’t paid according to the individual TPA agreement.

Before contracting with a payer, it’s essential for practitioners to determine which entity sets the cost of services and what those payments will be to the practice.

Different networks and commercial insurers for medical billing have their own set of rates and reimbursement requirements that must be met for clinicians to be paid and practitioners must conduct sufficient research to ensure they’ll be reimbursed appropriately.

Medical Billing — Its Role and What it Means to Your Office Structure

Medical Billing — Its Role and What it Means to Your Office Structure

A structured medical practice is essential to ensure that reimbursement claims are submitted in a timely manner.

Missing, lost, misplaced or improperly filed patient records creates unnecessary medical billing delays and interrupts the flow of funds into the practice.

billingOrganization is the key to a well-run practice that treats as many patients as possible and generates a steady stream of reimbursement claims for medical billing and coding specialists to process.

In the absence of clear cut rules, direction and procedures, waste and chaos results. Distracted billers can make costly mistakes.

Filing practices
Maintaining accurate and easy to access patient records is essential if a biller is to do his/her job. The information contained within the patient’s record is the basis upon which reimbursement claims are filed.

Incomplete, inaccurate or illegible records cause delays in medical billing and can easily result in a payment denial or rejection. The information needed to obtain payment must be maintained in a manner that allows billers to quickly access the information they need to submit claims.

Each to his own task
In smaller practices, staff members may be required to wear a variety of hats, including the clinic’s medical billing and coding specialist. While it’s possible for a clinic’s healthcare staff to multi-task by answering phones, looking up records, scheduling appointments and communicating with other healthcare facilities and pharmacies, it’s not conducive to medical billing practices.

Each team member should have set responsibilities and clear cut job descriptions to avoid wasted effort. That’s not to say that personnel shouldn’t be cross trained to handle other duties should the need arise. Clinicians need to plan for such contingencies and ensure staff has a clear understanding of what to do in specific circumstances.

Set office hours
Setting regular office hours allows patients to know exactly when the clinician is available and keeps practitioners from being pulled in too many directions at once. Scheduling appointments to see clients allows providers to best utilize their time and provides medical billing specialists with a steady stream of claims to submit throughout the day.

Some healthcare professionals prefer the walk-in method of seeing clients with no appointment necessary.

It eliminates the problems of cancellations and no-shows, but there’s no way to ascertain how many patients may or may not arrive.billing and documentation

Clinicians could find their medical billing specialists have few reimbursements to submit.

A well-structured office is one that operates efficiently and where every detail of a patient’s visit is carefully documented and filed for retrieval by the practice’s medical billing specialist.

Careful organization and an eye for detail ensures that billers have the information needed to process reimbursement claims to maintain a steady cash flow into the clinic.

Health Insurance and Its Top Three Mistakes or Issues

Health Insurance and Its Top Three Mistakes or Issues

There are three major mistakes within the office setting that are contributing to a loss of revenue through non-payment. The errors can easily be prevented and some can be eradicated before patients ever arrive for their appointments.

health insuranceClinics across the nation are feeling the effects of longer turnarounds on reimbursements and outright denials by health insurance companies to pay for services.

Verify Health Insurance Information Each Time Services Are Provided
The number one cause of denied reimbursement claims is a failure to verify health insurance information. Loss of employment and changes in insurance coverage can occur at any time. It’s essential that client coverage is verified for each patient anytime services are rendered.

Denials occur for any number of reasons, but the most common is the coverage has been terminated, followed by the patient being ineligible. Many health insurance plans require pre-authorization for procedures and have limits on benefits.

Failure to obtain permission or determine if the client has reached a maximum benefit amount will result in denial of payment. Practitioners should also ascertain if specific services are covered.

Current Patient Information Is Essential
They may seem like simple errors, but incomplete or incorrect patient information is the second most common cause of denials. Clinicians should ensure that the client’s name is spelled correctly and the date of birth is accurate, along with the address, complete contact information and gender.

Some patients have healthcare coverage through multiple providers, requiring clinics to perform additional checks to coordinate benefits. The policy holder and their relationship to the patient must be clear.

Each health insurance provider has its own set of rules for submitting claims and special attention should be paid to ensure those requirements are met.

Diagnosis, Procedure Codes and Sloppy Handwriting
Diagnosis and procedural codes provide essential information to health insurance companies about the patient’s condition, symptoms and treatment. Codes that don’t match the information provided can result in a denial on the grounds that the procedure wasn’t medically necessary or it doesn’t match an authorization.

Clinicians should ensure that their medical billing and coding experts are utilizing current codes and that they’re updated yearly. Another source of denials is poor penmanship on the part of the practitioner, a situation that is easily corrected with implementation of an integrated electronic medical record (EMR) system.

health insurance issuesNavigating the labyrinth of rules, regulations and requirements set forth by health insurance providers can be a daunting process.

Human error and failing to verify health insurance information complicates the process, leading to payment denials and loss of revenues.

Vigilance is the only cure for clinics still using paper records. Implementation of an EMR transitions clinics away from wasteful paper records and virtually eliminates the top three mistakes of health insurance claim submissions that rob practitioners of revenues.

Medical Terms Talking the Talk and How to “Get” Them, Part 2

Medical Terms Talking the Talk and How to “Get” Them, Part 2

Nitin Chhoda shares how to become familiar with terminology, tests, treatments and procedure.

medical termsBecoming fluent in medical terms becomes easier with practice, but to many it may seem as if they’re speaking a foreign language at first.

The prefixes, suffixes and root words aren’t part of the ordinary vocabulary for most people and medical jargon is a specialized language.

Along with medical terms, individuals working in a medical setting will also need to be cognizant of the terminology for tests, treatments and procedures.

Practice and Memorization Makes Learning Medical Terms Easier

Anyone in the medical profession must learn the medical terms and students of the healing arts have become proficient at developing strategies to help them memorize medical terminology. Committing small groups of prefixes and suffixes at a time to memory is only the beginning.

Begin seeking prefixes, suffixes and root word in literature, advertisements, magazines and even online. Associate suffixes and prefixes of medical terms with their meanings, dissect them into their component elements and try to determine the ultimate meaning. The technique is an easy and meaningful way to learn.

Medical Terminology for Treatments, Tests and Procedures

Along with a specialized vocabulary and understanding of anatomy, those in the medical profession will be required to have knowledge of medical tests, treatments and procedures. Tests are examinations that measure something about the patient, while a procedure is a course of action designed to achieve a desired result.

Treatments are also procedures, but a procedure relieves an illness or addresses an injury.

Suffixes and prefixes of medical terms will be used to describe treatments, tests and procedures, along with the specialties of those within the profession. For example, a physician may want a closer examination of a lump on a patient.

He/she will order a procedure (biopsy) to take a sample of the tissue, to be examined (test) by a doctor who identifies diseases of tissues (pathologist). If cancerous, chemotherapy (treatment) may be prescribed.

The importance of medical terminology becomes apparent when billing for services. There are hundreds of services that a clinician might be required to submit a reimbursement request for, from allergy tests to x-rays. The codes for various services must match the diagnosis, symptoms and results of the physical examination or the patient’s healthcare provider will deny the claim.

Medical terms, tests, procedures and treatments are all part of the medical billing learning process especially for those engaged in the medical profession, but there’s no need for individuals to panic or throw themselves into information overload.

medical terms and its definitionLearning a few prefixes, suffixes and root words at a time and practicing those skills by breaking down terms into their component parts will help train the brain.

Individuals will be surprised at how quickly medical terms become part of their vocabulary and how easy it is to understand and add new terms.

Medical Coder and Practice Staff’s Ethics are More Important than Their Typing Speed

Medical Coder and Practice Staff’s Ethics are More Important than Their Typing Speed

There’s a code of ethics that automatically comes into play in medical offices and employees are cognizant of this.

Staff and medical coder are aware that they can’t share personally identifiable information with outside sources, but what they don’t realize is that a casually made comment can also break the bonds of ethics and the law.

Medicalmedical coder billing and coding specialists deal with confidential information each day.

It’s important for them to perform their tasks with alacrity, but it’s imperative that their moral and ethical standards surpass their typing speed.

Practice owners want reimbursement claims filed as quickly as possible, but they can’t overlook or tolerate a breach of confidentiality no matter how efficient the medical coder is.

Practitioners have a myriad of state and federal agencies with which they must comply or they open themselves to lawsuits. A medical coder who gossips and shares patient information with anyone else is placing themselves at risk, along with the practice owner and the entire medical facility. Penalties can be leveled through civil, state and federal agencies.

Don’t run afoul of common, statutory, administrative and case law.

There are four law classifications by which clinics’ owner, staff and medical coder must operate – common, statutory, administrative and case law. They can be confusing and vague, but it’s essential that clinicians become familiar with each.

A practice is considered common law if it’s accepted as fact by the majority of the population. Common law practices don’t have the force of a governing entity behind them.

Statutory law is legislative in nature and can be created at the local, state and federal level. Administrative law encompasses sets of rules made by government bodies or officials that allow them to administer statutory laws. Case law is made by courts when they interpret administrative and statutory laws.

The penalties for loose lips are severe.

The penalties for breaking confidentiality not only by the medical coder but the rest of the practice staff are significant, far reaching and determined through civil law if a patient decides to sue. The court can rule to award monetary amounts to clients for medical expenses, lost wages and distress. In civil cases, some practitioners choose not to go before a jury, admit no guilt, and settle out of court for a specified monetary amount.

Medical coder may find themselves facing misdemeanor or criminal penalties for their lack of discretion, as well as the clinic owner by extension.

The consequences are fines and jail time for a misdemeanor. Those who violate HIPAA standards could serve jail time for a felony. Fines in such cases have ranged from $50,000 to over $4 million.

medical coder and staffMedical coder must treat each client’s data as highly confidential, even if it seems that a particular bit of information is common knowledge.

Stay vigilant

Patients must give permission before their information is shared and they must designate with whom. Those medical coder or other members of the practice who violate HIPAA codes in any way must be prepared for the consequences.

Failure to adhere to HIPAA regulations will result in litigation that can damage a practice so severely that it never recovers.

Even if everyone, including the medical coder involved, are found innocent, clinicians will contend with a loss of reputation, clients and revenue.

No matter how skilled a coder is at efficiently submitting claims, it’s not worth the risk if he or she doesn’t come equipped with a superior set of ethics.