All About Medical Billing
Not to be confused with medical coding, medical billing is the process of submitting and following up on claims to insurance companies.
This is a company who will check claims for accuracy and reformat them on the format specified by the carrier. Clearinghouses are a major part of a billing service's ability to conduct business.
Gathering & Entering Data
Paper Claims Processing
Electronic Claims Processing
In US about 500 million claims are generated per month, over 6 billion claims per year.40%of this claims are filed electronically and the remaining 60% are done by manually this is done in HCFA 1500 or CMS1500 format.
Congress has mandated electronic Claims Submissions format because Electronic Claims Processing reduces payment turn-around time by shortening the payment cycle
Electronic Claims Processing and Medical Billing can reduce average error rates to less than 1 or 2% by filing claims electronically.
Paper claims contain errors on them, which significantly reduces payment turn-around time. About 30 to 35% of all paper claims are rejected due to typos, errors and omissions. Electronic Claims are submitted to the carrier via modem after being checked for accuracy either by a billing service's software or claims Clearinghouse
This audit/edit process reduces the normal rejection rate of 30 to 35% down to around 1 or 2%. By checking electronic claims for accuracy up front, the claim is put in a payable status when the insurance carrier, thus reducing payment turn-around time, receives it
Annual healthcare expenditures increase by more than 10%. Each year, for the rest of this decade, it is estimated that there will be more than 4 million babies born, 20 million children will be below age 5, over 4 million people will reach the age of 45, and more than 2 million people will turn age 65. The average person accounts for 6 physician encounters per year. Some form of health insurance covers more than 220 million Americans. That's a lot of electronic claims processing services to provide!
Faster payment turn-around time (90-120 days down to 7-14 days), Requires no staff training or retraining. Usually no startup investment for the practice. Allows staff to focus on their patient's ills rather than their bills .Get paid on more claims because of reduction in errors. Reduces staff work hours and overhead expenses
In a study conducted by the American Medical Association, it was estimated to cost healthcare providers an average of $6 to $12 to file a claim. Using the services of a billing company, a physician will spend around $2 to $3 on each claim with Electronic Claims Processing.
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) required the Department of Health and Human Services (HHS) to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addressed the security and privacy of health data. As the industry adopts these standards for the efficiency and effectiveness of the nation's health care system will improve the use of electronic data interchange.
Enter the Payment received from the client or carrier
The process of posting payments creates balanced accounting entries from payment-related transactions – system created payments, manual payments, and canceled payments
Generating Super Bills
Types of Insurance coverage
Group Health Insurance provides medical expense coverage for many people in a single policy. All the eligible participants are covered, regardless of age or physical condition. Groups Coverage is ideal for International employees; missionaries, students and travelers are just some of the types of groups
2. Individual Policies
Any citizen can buy individual health insurance policies
The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation's largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people 65 years of age and older, some disabled people under 65 years of age, and people with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).
Medicaid is available only to certain low-income individuals and families who fit into an eligibility group that is recognized by federal and state law. Medicaid does not pay money to you; instead, it sends payments directly to your health care providers. Depending on your state's rules, you may also be asked to pay a small part of the cost (co-payment) for some medical services.
Medicaid is a state administered program and each state sets its own guidelines regarding eligibility and services.
Medicaid covers many groups of people. Even within these groups, though, certain requirements must be met. These may include your age, whether you are pregnant, disabled, blind, or aged; your income and resources (like bank accounts, real property, or other items that can be sold for cash); and whether you are a U.S. citizen or a lawfully admitted immigrant. The rules for counting your income and resources vary from state to state and from group to group. There are special rules for those who live in nursing homes and for disabled children living at home.
Your child may be eligible for coverage if he or she is a U.S. citizen or a lawfully admitted immigrant, even if you are not (however, there is a 5-year limit that applies to lawful permanent residents). Eligibility for children is based on the child's status, not the parent's. Also, if someone else's child lives with you, the child may be eligible even if you are not because your income and resources will not count for the child.
In general, you should apply for Medicaid if your income is low and you match one of the descriptions of the Eligibility Groups. (Even if you are not sure whether you qualify, if you or someone in your family needs health care, you should apply for Medicaid and have a qualified caseworker in your state evaluate your situation.)
Medicaid does not provide medical assistance for all poor persons. Even under the broadest provisions of the Federal statute (except for emergency services for certain persons), the Medicaid program does not provide health care services, even for very poor persons, unless they are in one of the designated eligibility groups. Low income is only one test for Medicaid eligibility; assets and resources are also tested against established thresholds. As noted earlier, categorically needy persons who are eligible for Medicaid may or may not also receive cash assistance from the TANF program or from the SSI program. Medically needy persons who would be categorically eligible except for income or assets may become eligible for Medicaid solely because of excessive medical expenses.
5. Personal Injury (PIP)
Personal Injury Protection (PIP) is an insurance coverage for medical and other expenses resulting from an automobile accident, for people specified in the policy, regardless of who is at fault in the accident
Washington's Mandatory Insurance law does not require PIP coverage on automobile policies. An insurance company is required to offer you the coverage when you buy an automobile policy. If you don’t want it you can reject it in writing. If you haven't signed the rejection the company must add the coverage and charge you a premium for it. (RCW 48.22.085 through RCW 48.22.100 and WAC 284-30-395)
The person named in the policy as the 'named insured', and residents of the named insured's household related by blood, marriage or adoption, step or foster children are covered for injuries incurred in an accident. Also passengers or pedestrians are covered. These people will be eligible for payments no matter who is at fault in the accident.
PIP covers reasonable and necessary medical expenses for injuries sustained in an automobile accident, up to three years from the date of the accident and up to $10,000. PIP also offers income replacement coverage limited to a maximum of $200 per week for one year, after a person has been disabled for 14 days after the accident. Funeral expenses of $2,000 and loss of services (payment to others for work you can't do) of up to $5,000 are also included in the coverage. Payments are made for costs that are actually incurred by the injured person
PIP doesn't cover injuries caused by using farm equipment, recreational or off road vehicles, mopeds or motor cycles (PIP coverage is available on motorcycle policies). It won't cover intentional injuries to the insured person or if the person is injured in organized racing activities or committing a felony.
Workers' compensation systems (colloquially known as workers' comp in North American English or compo in Australian English) provides compensation for employees who are injured in the course of employment. While schemes differ between jurisdictions, provision can be made for weekly payments in lieu of wages, compensation for economic loss (past and future), reimbursement or payment of medical and like expenses, general damages for pain and suffering and benefits payable to the dependents of workers killed during employment. Cash benefits are established by state formulas with maximum benefit level. The benefits are administered on a state level, primarily by the state department of labor.
These laws are usually a feature of highly developed industrial societies, implemented after long and hard fought struggles by trade unions. Supporters of such schemes believe they improve working conditions and provide an economic safety net for employees. Conversely, these schemes are often criticised for removing or restricting workers' common law rights in order to reduce governments' or insurance companies' financial liability.
TRICARE is the name of the Department of Defense’s managed health care program for active duty military, active duty service families, retirees and their families, and other beneficiaries. Under TRICARE, you’ll generally have three options for health care:
• TRICARE Prime
• TRICARE Extra
• TRICARE Standard (formerly called CHAMPUS) Here’s a look at each of the three options:
This is a voluntary health maintenance organization (HMO)-type option. If you decide to get your health care through TRICARE Prime, active duty members and their dependents have no enrollment fee. Retirees pay an annual enrollment fee and normally enroll for one year at a time. You should receive a TRICARE Prime handbook specific to your region when you enroll. This TRICARE handbook does not go into regional details on TRICARE Prime.
Also, you can “split” your family’s enrollment—that is, you can have different family members enrolled in TRICARE Prime in different TRICARE regions, at no additional cost. Or you can have some of your family in TRICARE Prime and other family members in the other programs. Your TRICARE Prime enrollment is “portable”—you can take it with you if you move from one TRICARE region to another, without having to disenroll in one region and reenroll in another, except when moving to and from an overseas assignment. You will need to notify your new TRICARE Managed Care Support Contractor (MCSC) upon arriving at your new location. Your new TRICARE MCSC will contact your former MCSC to ensure that your enrollment is properly transferre transferred.
Normally, you’ll receive your care from military providers in an MTF or from the TRICARE Prime network of civilian providers. An advantage of being enrolled in TRICARE Prime is the policy directed access standards for TRICARE appointments. They are as follows:
– Urgent care 24 hours
– Routine appointment 7 days
– Routine specialty care 30 days
– Wellness, health promotion 30 days
Kerala Medical Billing Company