Claim Reimbursement — The Billing Scenario

Claim Reimbursement — The Billing Scenario

Building a clean claim is a concerted effort. It begins with the office staff that gathers demographic information and comes to fruition when the funds are deposited in the practice’s account.

Much can happen to a claim on its way to becoming a payment and in this informative article, Nitin Chhoda provides unique insights into the pitfalls that face even perfectly prepared claims and elements that affect payment.

claimWhere’s the Claim?

Aside from coding errors, reimbursement claims can go awry in many ways. The insurance provider may not be known at the clearinghouse or the clearinghouse software may glitch and submit the claim to the wrong provider.

In some instances, the payer may not be using electronic medical records (EMRs) software necessitating submission of a paper claim.


Practices that utilize EMR technology receive a report in real time when a claim has been submitted. These receipts provide billers with critical information in the event of a problem. Occasionally, a claim will appear to vanish into the ether.

Clearinghouse reports tell billers when the claim was received, its status and if any problems were identified. If payment isn’t received in a reasonable time or it doesn’t appear on the biller’s daily verification, that data be used to track down the claim and rectify any problems.

Reimbursement Amounts

The whole point of submitting claims is to get paid, but the amount charged can conflict with what the payer is willing to reimburse. When differences occur, billers can easily refer to the contract the clinician has with the payer to define the reimbursable amount.

CTP codes are assigned a relative value that determines reimbursement amounts, derived from the Resource Based Relative Value Scale (RBRVS).  The value assigned is based on the work required, the cost of maintaining a practice and the malpractice/liability for which the practitioner is responsible.

A formula is then employed that takes into account geographical locations to calculate the reimbursement rate.


Some contracts are RBRVS based, some aren’t, and the differences in each can be immense. Depending on how the contract is written, procedures may be paid based on RBRVS standards or discounts applied for secondary procedures done at the same time.

Some may be paid at a higher rate determined by prioritization, while others are billed according to expected payment. If the contact doesn’t state which procedure is prioritized, it’s up to the biller.

The Deciding Vote

The ultimate decision lies in the hands of the company that provides the patient’s healthcare insurance. Once the clearinghouse completes its search for errors, it forwards the claim to the payer. When reimbursements are less than expected, billers must refer to contract terms to obtain the maximum payment allowed.

reimbursement claims

Many hazards await claims, from submission to the wrong payer to glitches in clearinghouse software.

EMRs facilitate the process by submitting claims in real time and documenting receipts from the clearinghouse.

Billing specialists can help clinicians boost revenues by carefully monitoring claims and referring often to contract details. Practitioners must negotiate their contracts carefully to ensure their services are adequately reimbursed.

What to Look for (and be Wary of) When Choosing Billing Software

What to Look for (and be Wary of) When Choosing Billing Software

Billing software will play a large part in the success of the billing process and getting paid. As an early implementer of medical software and an expert on electronic medical record (EMR) technology, Nitin Chhoda addresses what clinicians should seek in medical billing software.

billing softwareThe goal is to bill accurately and quickly. Ordinary billing software will work, but an EMR is recommended. It’s the new standard in medical billing software.

EMRs have functionalities ranging from submitting more clean claims to verifying patient insurance coverage. Billing software allows clinicians to collect payments quicker and provide an enhanced level of patient care.


Medical billing programs can cost from $500 to $5,000. The cost of an EMR that is integrated with billing software can reach $50,000, but the good news is that comprehensive EMR systems are available for free. Due diligence should be exercised and sufficient research conducted before purchasing any program.

Digital Delivery

While some insurance companies still require paper claims, the vast majority use digital delivery. Using billing software is fast, efficient and transmits claims to their destination in real time, allowing practitioners to get paid in as little as 10 days. It’s a requirement for government-operated insurance programs that include Medicare and Medicaid.


Today’s patients communicate in a variety of ways, from old-fashioned mail to voice messages. It’s critical for a practice’s billing software to be able to do the same. Billing programs should have the ability to contact clients by voice and text message, mail, phone and mobile device and email.

Access On the Go

Billing software places all of a patient’s information in a central location, but the programs also provide users with the ability to access client information from any location where an Internet connection is available.

Billers can update information from multiple locations, a particularly useful feature for practitioners with more than one office and those who participate in corporate wellness programs.


Even though an integrated EMR can take the place of virtually any office system, some clinicians are enamored of their existing programs and can’t bear to part with them. Any billing software program should integrate smoothly with other systems already being used in the office.

Clean Claims

A good billing software program significantly reduces the possibility of claim errors by identifying common mistakes before the reimbursement request is sent. Clean claims can be submitted to clearinghouses that are processed quickly and efficiently for quicker payment collection.

Tech Support

A key feature of medical billing software is the ability to access tech support 24/7. A bug or glitch in the software program can mean significant losses for the practice and payment delays. Billers should be able to work with tech support any time of the day or night to fix problems.


Maintaining HIPAA compliance is serious business and billing software helps practices avoid running afoul of state and federal regulations. Patient information is confidential and billing software assists users ensure that data and submissions are transmitted securely.billing software program

Billing software runs the gamut from basic systems to those with a comprehensive array of built-in abilities. Don’t purchase the first system that’s explored.

Do take time to examine each billing software program to ensure it will grow along with the practice and can be customized to accommodate the individual needs of the clinic.

Medical Terms Talking the Talk and How to “Get” Them, Part 1

Medical Terms Talking the Talk and How to “Get” Them, Part 1

Nitin Chhoda shares how to use prefixes, suffixes and roots to determine the anatomy of medical terminology.

medical termsThanks to a diversity of TV programs, some medical terms have found their way into common usage.

Most people know the meaning of IV and stat, but medical terms are notoriously difficult to spell and decode, making it essential that a medical billing and coding specialist has a working knowledge of the terminology used within the practice.

They can accomplish that by learning the three-part combinations that comprise medical terms.

Medical Terms Are a Combination of Prefixes, Suffixes and Root Words
Medical terminology is comprised of prefixes, root words and suffixes stemming from Greek and Latin. Prefixes appear at the beginning of words. The pre means before, as in preschool, but the prefix can also be used to designate a location, number or time.

The root portion of a medical term forms the central part of the word. An example would be the word premature, as in premature aging. Mature is the root word and the “pre” suffix is used to indicate an individual is demonstrating symptoms of aging that’s at odds with the subject’s chronological age.

Suffixes are used at the end of a word to change the meaning, as in hopeless. It means the absence of hope and reverses the entire meaning. It’s often used to describe a condition, disease, disorder or procedure.

Root words, prefixes and suffixes are combined to create medical terms. Broken down into its component parts, the term myocarditis translates into muscle heart inflammation – or inflammation of the heart. An idiosyncrasy of medical terminology is that the words can be somewhat out of order from what most people are used to seeing.

Prefixes of medical terms work independently of root words and specific prefixes will always refer to one thing. For example, the prefix endo will always refer to inner. It’s essential for billing and coding specialists to be familiar with common prefixes and suffixes used in medical professions.

It’s also helpful to know something of anatomy, as many terms refer to a specific area of the body.

A Tried and Tested Technique for Learning Medical Terms
The best way students in all branches of the medical profession have devised for learning medical terminology is to learn groups of three roots, prefixes and suffixes.

medical terminologies

For those with a limited knowledge of anatomy, it helps to learn the root words of common body parts and then associating prefixes and suffixes with a specific part of the body.

Medical terminology sounds extremely complicated, but many people have heard and retained information about medical terms without even realizing it.

Some even use the terms, but without fully understanding how prefixes and suffixes reflect a diagnosis. Learning a few medical terms at a time is more effective than trying to memorize dozens all at once and suffer information overload. Those who approach the task by learning small groups will be surprised at how fluent they become in a very short time.