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.

Supply, Demand, and Combatting Limited Reimbursements of Insurance

Supply, Demand, and Combatting Limited Reimbursements of Insurance

The way healthcare insurance is viewed and paid for has evolved significantly over the last century and the law of supply and demand is the rule of the day.

The business of selling insurance is a multi-million dollar industry, the sole purpose of which is to make money for the company providing the services.

insurancePatients no longer visit their local insurance provider to obtain coverage. Insurance is packaged and sold like cars and the latest deodorant through state-of-the art advertising agencies.

Supply and demand dictates that if there’s a consumer need for a service or product, someone will provide that product or fill that need.

The Law of Supply And Demand

Consumers mistakenly believe that as more customers enter the market and purchase insurance, the cost will eventually go down. In a capitalistic system, that’s not necessarily true. If the revenues to be made are great enough, the cost will continue to increase as insurance providers strive to make ever greater profits.

Healthcare insurance providers charge the maximum amount that the market will allow for premiums.

The result is that consumers pay more for their healthcare insurance and malpractice insurance continues to skyrocket for medical professionals. Practitioners must charge sufficiently for their services to cover these costs and make a profit, while remaining competitive enough to attract new clients.

Payments versus Actual Costs

Healthcare insurance typically pays hospitals, labs and medical providers a set fee for services. In many instances, that payment doesn’t cover the actual costs involved.

Medical professionals must then decide if they will accept the insurance reimbursement as full payment, bill the difference to patients and face additional costs involved in collecting the debt, or if they want to offer the service at all.

To offset costs, medical providers need to create multiple revenue streams. Depending upon factors that include geographic location, clientele, patient load and availability, clinicians can do this through a wide variety of means. They can charge parking fees, write a book, schedule speaking engagements, add new services or develop new products.

Playing the Money Game

The primary way practitioners are paid is through reimbursement claims, which is normally prepared by medical billing professionals, to insurance companies, but there’s a dirty little secret lurking in the shadows. Insurance companies invest the funds they collect from clients to make more money. Each month that the firm can retain those funds, the company makes more on its investments.

That means healthcare providers are often forced to wait for up to three months to be reimbursed for their services. Insurance providers have teams of specialists whose job it is to calculate the fair market price for medications, office procedures and surgical interventions.

Insurance companies say these teams are eliminating waste, but the truth is that their job is to identify ways to reduce reimbursements paid to medical professionals.healthcare insurance

Clinicians who choose not to offer specific services run the risk of losing clients to competitors who do.

If they accept insurance company reimbursements as the total payment for services rendered, they lose money.

Increasing patient numbers is one way to grow a clinic’s revenues, but creating multiple revenue streams is the most desirable. Funds coming in from a wide variety of sources will benefit practices in times of feast or famine.

The Four Ds of Negligence

The Four Ds of Negligence

Nitin Chhoda shares the four Ds of negligence in a private practice setting so that clinicians can prevent negligence from occurring in the business.

negligenceThe medical profession is a rewarding one, but full of opportunities to inadvertently run afoul of rules and regulations. Most patients are sincere.

They simply want to get better or see an end to their pain, but there exists a pool of unscrupulous clients who are vigilant in their search for a reason to sue a medical provider for a breach in one of the four Ds of negligence.

The four Ds encompass duty, dereliction, direct cause and damage. The majority of healthcare practice management providers won’t experience the harm to their reputation, clientele and clinic that result from a lawsuit, but medical professionals should be aware that they can be held liable vicariously through the actions of their staff.

To avoid the four Ds of negligence, it’s essential that everyone is conversant in the proper procedures. To be guilty of negligence, a disgruntled patient must prove that the practitioner took action, or failed to, that was ultimately detrimental to the client.

Clinicians should be wary of patients that come into the office requesting specific medications, tests and treatments.

1. Where Duty Begins and Ends

The first of the four Ds refers to duty. Clinicians have a duty to their patients to provide the most accurate diagnosis and care, utilizing their extensive education and experience. Healthcare workers have a duty to inform patients of potential problems they observe upon examination in the clinical setting. They’re under no obligation to provide medical information about any condition they notice in connection with strangers and casual acquaintances, which is a part of negligence.

2. Dereliction of Duty

Dereliction is the second of the four Ds of negligence and refers to actions that a healthcare provider may fail to take. If a medical professional observes a skin condition that could be cancer but neglects to inform the client, it’s a breach of duty.

3. Making a Bad Situation Worse – the Direct Cause

Direct cause is the third element of the four Ds. In this type of negligence, the onus is on the client to prove that the healthcare provider knew about a potential risk, didn’t inform the patient, and the client was injured as a result.

4. Collecting Damages from Clinicians

Rounding out the four Ds of negligence is damages patients can collect in a lawsuit. Damages are the financial compensation clients can collect and includes lost wages, medical expenses and mental duress.

Vicarious and Collateral Liability

Practice owners can be held liable for staff members who make mistakes, don’t follow proper procedures or overstep the boundaries of their responsibilities.

negligence of practice

That includes defamation of character, slander and making libelous statements. It also encompasses invasion of privacy, sharing records without informed consent, violating patient care standards, and malfeasance.

Medical practitioners must work within established laws and parameters when treating patients and ensure staff members are cognizant of what constitutes a breach of the four Ds of negligence.

Staff must be trained in potentially litigious situations for themselves, the practice and the consequences. Education, an understanding of procedures and identifying clients that may come equipped with a lawsuit mentality will help anyone in the medical profession avoid the four Ds.

Healthcare Insurance Simplified – the Patient’s Perspective of Health Coverage in the New Economy

Healthcare Insurance Simplified – the Patient’s Perspective of Health Coverage in the New Economy

Although healthcare insurance can be useful in the case of illness, many people do not understand their insurance coverage and limitations.

Nitin Chhoda shares the different perspective of healthcare insurance; from that patient’s point of view to the healthcare service provider.

healthcare insurancePatients and therapists view healthcare insurance from an entirely different perspective.

For patients, it’s a way to defray costs when they require a wide range of services, from prescriptions and hospitalization to well patient check-ups and ongoing physical therapy treatments.

For therapists and healthcare practice management providers, healthcare insurance is the primary means of reimbursement for services.

Healthcare Insurance

Older clients, parents and those who have experienced the need for an extended hospital stay are well acquainted with the value of maintaining a comprehensive healthcare insurance policy. They may complain about the cost of premiums, copays and deductibles, but they know the benefits far outweigh the monetary sacrifices they may make to keep their coverage up to date.

Younger individuals tend to eschew healthcare coverage or purchase less than they need. For this demographic, accidents and healthcare emergencies are incidents that happen to “other” people.

healthcare insurance simplifiedThe entire healthcare insurance industry is a mystery to most patients. They’re unsure of exactly what they’re paying for, the terms of their coverage and their financial responsibility.

Healthcare insurance is often far more expensive than they anticipate, may not cover a wide variety of treatments and procedures, and involve high deductibles that must be met before coverage is available.

A Patient’s Perspective

Millions of individuals across the nation live in constant fear of becoming ill, injured or incapacitated, even when they have insurance. When they do become ill, it may be difficult to find a healthcare insurance provider that accepts their brand of insurance.

Patients often delay treatment, spreading potentially dangerous diseases. When no other option exists, those same clients resort to emergency room treatment that contributes largely to the increasing cost of healthcare costs.

As it exists, the healthcare industry in the U.S. forces patients to make decisions that can radically influence their lives and future finances.

The Affordable Care Act provided coverage to millions who were uninsured or underinsured, but it also created a deficit of healthcare insurance providers in relation to the number of new patients coming into the system.

Those who don’t understand their coverage represent a major loss of income for therapists. When claims for non-covered expenses are rejected, patients must pay the bill and collecting those funds can be a costly endeavor.

The first steps in healthcare reform have been taken, but more must be accomplished. The future of healthcare insurance in the new economy will require patients to pay more for their healthcare coverage and shoulder more of the financial burden in terms of co-pays and deductibles.

Coverage and Limitations

Coverage caps and limitations could very well become the norm. For therapists, the result of such trends is a loss of income and a potential move toward more self-pay patients, a strategy that could effectively eliminate many from the healthcare system and cost practices in the long-term.

The experience and expertise of a good therapist can’t be understated and they deserve to be compensated for that acumen. Therapists are the chief advocates for their patients’ needs, but are often forced by healthcare insurance companies to accept far less for their services than the actual value or are second-guessed by insurance company officials.

It’s neither an efficient or cost effective system, and one that can potentially place patients in harm’s way while contributing to a system that makes it increasingly difficult for therapists to operate a financially sound practice.