4. DATE OF SERVICE
ONCE THE APPOINTMENT IS
FIXED, PATIENT COMES TO
THE DOCTOS OFFICE AND
FILLS THE DEMO FORMS (i.e.,
his address with contact #,
DOB, Gender, SS#, Employer
Information, policy name
and number, effective date
etc.) and signs the Breach of
Confidentiality.
6. MEDICAL TRANSCRIPTION
DOCTORS GIVE THE
DICTATION TO THE MEDICAL
TRANSCRIPTIONIST FOR
MEDICAL RECORD KEEPING.
(AS IT IS MENDATORY IN USA
TO KEEP THE MEDICAL
RECORD OF THE PATIENTS AT
LEASET FOR 5 YEARS).
7. MEDICAL CODING
AFTER THE MEDICAL
TRANSCRIPTION IS DONE, THE
DOCUMENTS / REPORTS ARE SENT
TO THE MEDICAL CODING
DIVISION TO GET THE REPORTS
CODED AS CPT (CURRENT
PROCEDURAL TERMINOLOGY) AND
ICD (INTERNATIONAL
CLASSIFICATION OF DISEASE) WITH
THE HELP OF CODING BOOKS AND
MAINTAINING CODING
GUIDELINES.
8. MEDICAL BILLING
ONCE THE CODING IS
OVER THE CODED
REPORTS / SUPERBILLS
COME TO THE BILLING
DEPARTMENT, WHERE
BELOW MENTIONED
STEPS ARE FOLLOWED:
9. DEMO ENTRY
DEMOGRAPHICS OF THE NEW PATIENTS ARE
ENTERED INTO THE BILLING SOFTWARE AND
UPDATION OF THE OLD ACCOUNS ARE DONE.
10. CRITICAL FIELDS – DEMO ENTRY
PATIENTS INFORMATION:
1. NAME
2. DATE OF BIRTH
3. GENDER
4. SOCIAL SECURITY NUMBER (SS#)
5. ADDRESS (INCLUDING ZIP)
6. CONTACT NUMBER
7. RELATIONSHIP TO THE INSURED
8. MARITAL STATUS
INSURED’S INFORMATION:
1. ID Number
2. Name
3. Address )including Zip code)
4. Policy and Group Name
5. Insured’s Plan or Program name
6. Insured’s Date Of Birth
11. CLAIM GENERATION OR CHARGE
ENTRY
ONCE THE ACCOUNT OF THE PATIENT IS CREATED IN
THE BILLING SOFTWARE, CHARGE CAN BE POSTED.
12. CRITICAL FIELDS – CHARGE ENTRY
a. Is the Patient’s Condition Related to: Employment, Auto Accident,
Other Accident
b. Name of Referring Physician
c. ID Number of Referring Physician
d. Diagnosis Codes
e. Prior Authorization Number (if applicable)
f. Dates of Service & Date of Hospitalization (in case of Inpatient)
g. Place and Type of Service
h. CPT
i. Modifiers (if applicable)
j. Linked Diagnosis Codes to the Procedure Codes
k. Days or Units (if applicable)
13. CLAIM SUBMISSION
There are two ways to submit the claims to the insurance companies:
1. Electronic Data Interchange (EDI) / Electronic Media Claims submission (EMC): EMC is
an electronic claims processing system that enables a provider to submit his/her claims
to the carrier by using there 5 digits payer id # more efficiently than the paper claims
2. Paper Submission on different forms (such as CMS 1500, CMS 1450 or UB 92, ADA
992000)
Time taken by Medicare to pay a clean claim: Medicare statute provides for claims payment floors
and ceilings. A floor is the minimum amount of time a claim must be held before
payment. A ceiling is the maximum time allowed for processing a clean claim before
Medicare owes interest to the Provider of Services.
Physicians and suppliers who file Paper Claims will not be paid before the 26th day after the date
of receipt of their claims. Clean claims filed Electronically will be paid not sooner than
13 days after receipt.
14. CLAIM ADJUDICATION
Processing of paper claims starts in the mailroom where the
envelops are opened, attachments unstapled, and clipped
to the claim. Claims are then scanned into the computer.
Processing of electronic claims begins when a file of
transmitted claims is received from the clearinghouse. (The
clearinghouse edits the claims before sending to the
insurance companies) and is opened in the claims
processing computer.
15. STEPS (CLAIM ADJUDICATION) -
1. The computer scans each claim for patient and policy identification
and compares them with the master policy file.
Claims will be automatically rejected if the patient and subscriber
names do not match exactly with the names on the master policy
list. Use of nicknames or typographical errors on claims will cause
rejection and return, or delay in reimbursement to the provider
because the claim cannot be matched with the names on the
master list.
2. Procedure codes on the claim form are matched with the policy’s
master benefit list. In the case of managed care claim, both the
procedures and the dates of service are checked to ensure that
services performed were authorized and performed within the
authorized dates of services.
16. CLAIM ADJUDICATION – Cont.
Any service determined to be a non-covered benefit is marked as an
uncovered procedure or non-covered procedure and rejected for payment.
Services provided to a patient without proper authorization or that are not
covered by a current authorization are marked as an unauthorized service.
Patients may be billed for uncovered for non-covered procedures, but not
for unauthorized services.
3. Procedure codes are cross-matched with the diagnosis codes to ensure
the medical necessity of all services provided. Any service that is
considered not “medically necessary” for the submitted diagnosis code
may be rejected.
4. The claim is checked against common data file. The information
presented on each claim is checked against the insurer’s common data file,
which is an abstract of all recent claims filed on each patient. This step
determines whether the patient is receiving concurrent care for the same
condition by more than one provider. This function further identifies
services that are related to recent surgeries, hospitalizations, or liability
coverage's.
17. CLAIM ADJUDICATION – Cont.
5. A determination is made by “allowed charges”. If no irregularity or
inconsistency is found on the claim, the allowed charge for each covered
procedure is determined. (The allowed charges is the maximum amount
the insurance company will pay for each procedure or service, according
to the patient’s policy. The exact amount allowed varies according the
contract and is less than or equal to the fee charged by the provider,
Payment is never greater than the fee submitted by the provider).
6. Determination of patient’s annual deductible obligation is made. (The
deductible is the total amount of covered out-of-pocket medical expenses
a policyholder must incur each year before to insurance company is
obligated to pay any benefits)
7. The co-payment or co-insurance requirement is determined.
18. 8. The Explanation of Benefits (EOB) is completed. The (EOB) form or
report is a statement telling the patient or provider how the insurance
company determined its share of the reimbursement. The report includes
the following:
a). A list of all procedures and charges submitted on the claim form.
b). A list of any procedure submitted but not considered a benefit of the
policy.
c). A list of all the allowed charges for each covered procedures.
d). The amount of the patient deductible, if any, subtracted from the total
allowed charges.
e). The patient’s financial responsibility for cost sharing (co-payment for
this claim.
f).The total amount payable by the insurance company on this claim.
CLAIM ADJUDICATION – Cont.
19. 9. EOB and benefit check is mailed. If the claim form stated that direct
payment should be made to the physician, the reimbursement check and a
copy of the EOB will be mailed to the physician. This can be accomplished
in one of three ways:
a). The patient signs the Authorization of Benefits Statement, Block 13 on
the CMS – 1500 form.
b). The Physician marks “YES” in Block 27 on the CMS – 1500 form.
c). The Physician has signed an agreement with the insurer for direct
payment of all claims.
If reimbursement is to be sent to the patient, the policyholder will received
a copy of the EOB; explanation is sent to the provider by most carriers,
without payment.
CLAIM ADJUDICATION – Cont.
20. PAYMENTS
PAYMENTS: Amount paid to the physicians against the services rendered by them to
the patient.
THE SERVICES THAT ARE PROVIDED TO THE PATIENTS ARE SENT OUT TO THE INSURANCE
COMPANIES IN THE FORM OF CLAIMS. THESE CLAIMS GET PAID BY THE INSURANCE COMPANIES.
THE PAYMENTS ARE RECEIVED AT THE PROVIDER’S MAILING ADDRESSES AND / OR AT THE BILLING
COMPANIES’ ADDRESSES. IN CASES WHEN THEY ARE RECEIVED AT THE PROVIDERS’ ADDRESSES
THEN THEY ARE IN TURN FORWARDED TO THE BILLING COMPANY TO THE PAYMENT IN THEIR
SYSTEM. SUCH PAYMENTS COME IN THE FORM OF BATCHES AND MAY HAVE BANK’S DEPOSIT SLIP
OR PAYMENT LISTING WITH THEM. PAYMENTS THAT ARE RECEIVED DIRECTLY AT THE BILLING
COMPANIES’ ADDRESS DO NOT HAVE THE BANK’S DEPOSIT SLIP. PROVIDER CAN ALSO SIGN-UP FOR
ERA (ELECTRONIC REMITTANCE ADVICE ) AND EFT (ELECTRONIC FUND TRANSFER )
SOMETIMES, IN THE CASE OF NON-PARTICIPATING PROVIDER’S, PAYMENTS ARE RECEIVED BY THE
INSURED PARTIES ADDRESS AND THEY FORWARD THE PAYMENT TO THE PHYSICIAN’S ADDRESS.
21. DENIALS
Claim that do not get paid, come back as Denials from the Insurance
carriers. This can be due to posting errors, incorrect procedure / diagnosis
codes, lack of information (medical records) while filing the claims, or
missing / incomplete patient details.
Denials are broken down into two categories: In-House and Patient
Responsibility.
In-House denials are the ones that require some type of correction from
our part and can be resubmitted. We do not bill patient.
Patient Responsibilities are those denials that we can’t do anything to get
the claim paid by the insurance company. Al we can do is, transfer the
charge to the patient with the correct message code.
22. A/R MANAGEMENT
The following guidelines are intended to assist staff who are engaged in
Third Party or self follow-up. The guidelines are consistent with the
Fair Debt Collection Practices Act. It is important for the billing
service, as a third party involved in the billing and collection of our
client’s accounts, to confirm our guidelines to the Act to the assure
the protection of the billing service and it’s clients.
CAUTIONARY GUIDELINES
Before placing a follow-up call:
1. Review Insurance A/R aging report.
2. First focus on accounts with aging 120+ days and large balances, You’re your
way down up to 45 days of balance outstanding.
3. For Self-Pay patients, after one statement has gone out, F/U should be done
after 30 Days from the date statement was mailed.
4. Review account notes and transaction history. Make sure that the billing
service is not at fault.
5. Plan what you want to say before making a call.
23. A/R MANAGEMENT – cont.
When making Call:
1. Call between 9:00 am. and 5:00 pm. (CST- Time)
2. Know whom you are speaking to.
3. Identify yourself properly – do not represent yourself as calling from the Doctor’s office.
You are a third party billing service (e.g. Hello, my name is ___________. I am calling from
___________ (billing service name). We are the billing service for Dr. ___________.)
4. Do not leave messages on voice mail or on answering machines that imply a problem with
an account or any confidential information – you do not know who will retrieve the
message. General messages to return your call is permissible.
5. When need arises to threaten a guarantor with the collection, you should always say :
“We may refer your account to a collection agency or to an attorney for further collection
action.” It is important to remember that any threatened collection action must be taken if
there is no change in account circumstances. Not all clients will transfer account to
collection, please refer to client profile before threatening with taking such action.
6. If the debtor states that an attorney is handling his debts – refrain from any future contact
with the debtor and direct all communications to the attorney.
24. A word about fraud and abuse…
Fraud and Abuse Guidelines
Fraud: “Intentional” deception or
misrepresentation that someone makes knowing it
is false, that could result in an unauthorized
payment.
Abuse: “Actions that are inconsistent with accepted
sound medical, business or fiscal practices. Abuse
directly or indirectly results in unnecessary costs to
the [Medicare] program thru improper payment.”
25. Coding and billing as an identified potential
risk area for fraud and abuse
Billing for items or services not rendered or not provided as
claimed (fraud)
Submitting claims for equipment, medical supplies and services
that are not reasonable and necessary (abuse)
Double billing resulting in duplicate payment (abuse)
Billing for non-covered services as covered (fraud)
26. Coding and billing as an identified potential
risk area for fraud and abuse
Knowing misuse of provider identification numbers, which
results in improper billing (fraud)
Unbundling (assigning multiple codes for a service that is
covered by a single comprehensive code) (fraud)
Failure to properly use coding modifiers (fraud)
Clustering (selection of the same level of E/M service
repetitively) (abuse)
Upcoding or coding at a higher level of service than actually
provided (fraud and abuse)
27. Tips to prevent fraud and abuse
related to coding:
Never make changes to a diagnosis code or CPT code on a claim
or edited invoice without evaluating the documentation first
Use the correct version of ICD-9-CM/CPT/HCPCS based on the
date of service
ICD-9-CM codes should be selected to the highest specificity
based on documentation
Select the CPT code which best describes the service performed.
For services that do not have a specific CPT code to describe, use
the unlisted code from the appropriate category
When using a CPT modifier, make sure the combination with the
CPT code is appropriate
28. Tips to prevent fraud and abuse
related to coding:
When using a CPT modifier, make sure the combination with the
CPT code is appropriate
Use a comprehensive CPT code if available in reporting a
procedure or surgery. Never use multiple codes to describe a
service when a single comprehensive code is available
Familiarize yourself and stay up to date on payer coverage
policies that you frequently code
Communication: keep providers well informed regarding
documentation and coding requirements
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