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.
For the approximately 80 million individuals who already have healthcare insurance through an employer-offered policy, they won’t have to purchase coverage on the Health Insurance Marketplace.
They can keep the policies they have but may be taxed on them, depending on the plan’s value.
Some employers will drop insurance plans, opting instead to pay the government mandated fine.
In those instances, individuals will simply head to the Healthcare Insurance Marketplace and purchase their coverage there.
Essential Services and Benefits
Obamacare remains a mystery for many Americans, but it adds a variety of mandatory benefits and protections. It limits the amount that can be contributed to flexible spending accounts (FSA) by employers to $2,500 and increases the penalty for purchasing non-allowable items to 20 percent.
Beginning Jan. 1, 2014, all healthcare policies will be required to offer a core of essential services, ranging from prenatal care to hospitalization and prescription medications. Preventative and wellness screenings, tests and consulting services will be available free of charge.
Insurers can no longer place annual or lifetime caps on benefits.
Children will be allowed to remain on parental policies as dependents until they turn 26 and no one can be refused insurance for a pre-existing medical condition, or be charged more for their coverage than others.
Insurance companies can’t cancel policies for frivolous reasons and they must spend at least 85 percent of revenues toward patient medical costs or make up the difference with patient rebates.
Many individuals will be denied coverage as a dependent on a spouse’s policy due to wording in Obamacare.
Spouses will be required to obtain insurance through their own employer or the Marketplace. Taxpayers can deduct up to 10 percent of their medical expenses, but that portion of the law doesn’t include seniors until 2017.
In anticipation of those mandatory healthcare services, many insurance companies have increased premiums, deductibles and co-pays. Those costs are being passed on to employees, along with higher out-of-pocket costs.
People who have what the federal government deems as a “Cadillac” policy will be taxed according to the plan’s value.
People who typically purchase private health insurance may find lower prices in the Marketplace. Policies that were in effect prior to March 23, 2010 can receive “grandfathered” status, making them exempt from most of the new rules and regulations under Obamacare.
Medicaid and Medicare
Obamacare expands the eligibility requirements and income levels, allowing millions of additional patients to receive healthcare services through state Medicaid programs, along with the Children’s Health Insurance Program.
Some states with generous Medicaid parameters may push recipients out of the system when states are forced to adhere to Obamacare regulations.
Medicare recipients will see the closing of prescription gaps by 2020 and the ability to receive some services at home to prevent hospital stays and placement in nursing homes.
Every segment of the population will see changes due to Obamacare. Some will be immediately apparent, while others will be phased in over the next 10 years.
For workers with employer-provided policies, the changes will mostly come in the form of higher costs, but as President Obama has said many times, “If you like your healthcare plan, you will be able to keep your healthcare plan.”
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.
The Affordable Health Care Act, known as Obamacare, impacts private practices in multiple ways, but nowhere is that more evident than a pilot program of Accountable Care Organizations (ACOs).
An ACO is a group of healthcare providers that work as a team to deliver and manage patient care. Primarily aimed at Medicare patients, the goal is to prevent hospital admissions and readmissions.
It’s one of many initiatives that Obamacare is utilizing as a means of lowering healthcare costs. The outcome of the program could affect the entire way that care is delivered to seniors.
If the new method becomes the standard, it will affect any private practice that isn’t part of an ACO.
Composition And Rewards Of An ACO
The ACO is multi-disciplinary team composed of hospitals, clinicians and home care providers that are charged with providing primary and ongoing care. Services are bundled and a flat fee is paid to the team.
Bonuses will be paid when teams provide quality care that falls below a to-be-determined dollar amount.
ACOs attempt to limit costs through the reduction of “unnecessary” tests and procedures, and less usage of expensive technologies. ACOs that reach target wellness goals can keep any savings for themselves.
Home monitoring and the services of nurse practitioners, physician assistants, dietitians and care coordinators are encouraged.
At the end of three years, the information will be used to evaluate the program and discover areas where the greatest savings were found. The data will be examined by the Patient Outcomes Research Institute created by Obamacare.
The Independent Payment Advisory Board will be free to enact laws based on the Institute’s final results.
Private Practice Concerns
The financial rewards can be great for ACO participants, but if the pilot program becomes the standard, it will significantly reduce revenues for clinicians in private practice. Medicare patients will be initiated into an ACO that will handle their care from the beginning of a medical episode and for up to 30 days following discharge.
Practices that rely heavily on technology will be most affected.
It’s conceivable that private practitioners will be required to participate in an ACO or lose a significant number of patients and corresponding revenues. Some clinicians are facing pressure to sell their practices to local hospitals to become cogs in an ACO.
Practitioners will need to find alternative revenue streams that could include the sale of supplements, medical products or becoming a concierge practice.
Patient Fears For The Future
Obamacare functions on the assumption that ACOs will replace the current treatment and reimbursement model.
Many patients are concerned that the quality of their healthcare will suffer and access to technology will be limited as ACO teams prescribe treatment with an eye to a financial bonus at the end of the encounter.
The Possible End Of Employer-Based Insurance
ACOs have the potential to replace employer-based insurance. Instead of contracting with insurance carriers, employers could choose to join an ACO network to provide care for employees.
Private practices derive a significant portion of their patient base through contracts with employer-provided insurance plans.
The ACO model is an inclusive group that disperses work throughout its members. Clinicians could find their access to patients limited if they’re not ACO participants.
ACOs will affect patients and practitioners in various ways.
The driving force behind Obamacare is finding ways to save money, particularly in the Medicare arena. ACOs are touted as a means to rein in costs while providing quality care. To accomplish that goal, clinicians may have to be prepared to become an ACO participant, and patients may have to be content with less access to technology if it’s deemed too expensive.
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.
The Affordable Health Care Act, known as Obamacare, will affect people in different ways, Coverage is guaranteed either through the Healthcare depending upon their situation. Marketplace or expanded Medicaid programs.
Obamacare promises affordable healthcare, but the term affordable is based on a government formula and it doesn’t necessarily mean cheap.
The Department of Health and Human Services estimates the average cost of a Marketplace plan will be $328 per month for mid-level coverage.
Four plans are offered in the Marketplace – bronze, silver, gold and platinum – each with different levels of out-of-pocket expenses.
The lowest average catastrophic plan premium is estimated at $129 per month.
Essential Medical Coverage
Everyone covered with an insurance plan, whether it’s a purchased policy, Medicare or Medicaid, are entitled to a core group of services ranging from hospitalization and prescriptions to lab tests.
Many preventative tests, wellness screenings and counseling services can be obtained at no cost to the patient.
Employees with coverage through their employer don’t have to apply through the Marketplace. If the cost of an employer policy is more than 9.5 percent of the worker’s wages, then they can apply for insurance through the Marketplace.
Pre-existing Conditions And Breaks For Children
Patients with any type of pre-existing medical condition can’t be turned down for coverage or charged more than other policyholder.
Children can now remain on parental insurance policies until the age of 26.
Spouses May Not Qualify As Dependents
Spouses may not be eligible for family coverage under Marketplace policies. Obamacare provides the means for the primary policyholder to cover dependents (children) but spouses are not necessarily considered dependents any longer.
In plans that don’t count spouses as dependents, individuals will be responsible for obtaining coverage through their own employer or buying a plan through the Marketplace.
Medicare And Seniors
There will be no change in how Medicare recipients choose their physicians and Obamacare will completely close the gap in what they pay for prescriptions by 2020, once a deductible of $4,750 is met. After that, seniors pay 5 percent of the cost for the remainder of the year.
Seniors with high medical needs will be able to receive basic care in their home to reduce and prevent hospital stays.
Couples with yearly earnings of $200,000 or more will see a tax rate increase of .9 percent for Medicare Part A coverage and a new income-related premium will be established for Medicare Part D.
Many consumers will qualify for federal subsidies to help them purchase coverage on the Marketplace. Financial assistance is dependent upon household income.
The cost of the policy will depend on the coverage selected, the person’s income and the geographic area in which the policyholder lives.
The Individual Mandate Tax (IMT)
Anyone who chooses not to obtain insurance will be assessed a penalty on their income tax returns. Fines begin at $95 for adults and $47.50 for children in 2014, escalating to $695 for adults and $347.50 for children in 2016.
Interest accrues on unpaid amounts and fines can be deducted from any refund that’s due.
Exemptions from the IMT are available for certain religious groups, members of Native American tribes, and those who are incarcerated.
Also exempt are people with incomes of $9,500 or less who aren’t required to file a tax return, along with those whose premiums would exceed 8 percent of their income after employer contributions and federal subsidies.
Obamacare will affect everyone in different ways. For some, it will mean access to healthcare services for the first time. Others will see an increase or decrease in their coverage costs, depending on the type of policy they currently have.
Most consumers will have to wait to see exactly how Obamacare will impact them now and in the future.