In the healthcare industry, the term ‘medical clearance’ may not only refer to the documentation and forms required for work applications, or before beginning a fitness program. It can also refer to as ‘pre-operative clearance’ or ‘surgical clearance’ among many others. 

There is a lot of debate circulating on this subject. However, in the context of surgery, pre-operative clearance is a kind of authorization from a doctor or physician that tells if a patient is healthy enough to undergo surgery.

What’s the Purpose of Preoperative Clearance?

Healthcare practitioners have long been debating its purpose. While the term ‘clearance’ serves as a formal document that ‘clears’ a person for a proposed surgery, some argue that it can be misleading. 

Cardiologist Dr. George Marzouka believes that “calling a preoperative evaluation a ‘clearance,’ belittles the assessment’s purpose, and provides little in terms of meaningful information to the surgeon. It misleads patients, and possibly surgeons, by implying a sense of security that is not based on reality.” According to him, preoperative clearance’s purpose is to “assess what medical problems are present and how those problems might affect a person’s operative risk.”

During surgeries, unforeseen complications can arise. That’s why preoperative clearance should be used as an assessment rather than mere documentation. However, the documentation side of preoperative clearance’s purpose is to help healthcare organizations record and assess a patient’s medical history, diagnosis, and treatment. It is important that the right coding should be attained.

The Right Way To Code A Preoperative Clearance

Every medical practice uses medical coding for patient records and documentation. This is why like any other document, a pre-op clearance should be free from errors. This will help you assess if you’re coding a surgical clearance the right way.

These are ways how to make sure you’re doing it correctly:

1. Know that not all patients require it

Determining a patient’s condition is one of the purposes of a preoperative clearance. Preoperative visits should be done if the doctor attending requires it. Most of the time, healthy patients needing minor surgeries don’t need to undergo a preoperative examination. Surgeons, too, can identify if surgery is medically necessary without the need of a preoperative clearance from a physician or specialist.

2. Identify who should perform it

Not everyone in the medical field is allowed to perform preoperative clearance. Mostly, specialists and internal medicine physicians are those who typically manage patients’ conditions that might affect them during surgery.

Most of the time, surgeons can also perform pre op clearance after the decision for surgery has been made. However, it is important to note that the surgeons’ fees for these preoperative evaluations are already included in the global surgical package and shouldn’t have separate billings. 

Apart from these, the global surgical package includes related subsequent visits that happen before surgery, once a surgery decision has been made. When doing medical billings for surgery-related practices, make sure to know what fees are already included in the package, because this part is often overlooked.

3. Report at least three pre op ICD 10 codes

Processing of medical billings is heavily reliant on codes. For pre-op clearance, it will require ICD-10 codes that should have accurate information about (1) the intent for pre-op clearance (or Z01.81x), (2) The diagnosis for the requested clearance, (3) the diagnosis of the patient to undergo surgery.

You should also consider additional specifications for surgical clearance ICD-10 code Z01.81x. For example, a preoperative exam might require a cardiovascular exam, respiratory exam, laboratory exam, and other pre-procedural exams. These should be done in support of the purpose of the preoperative exam.

Related: A Beginner’s Guide To Medical Coding Terms

4. Medical necessity should be supported by documents

Like any other medical transaction and operations, a pre-operative clearance’s purpose should be supported by factual documents. This is done to justify that it is medically necessary for the patient to undergo s

This documentation must have this information:

• All the evaluated medical conditions of a patient by a physician in able to clear him for surgery
• Is the patient cleared for surgery? Why?
• Is the patient not cleared for surgery? State the reasons and the necessary course of action to push clearance.

5. Distinguish ‘Decision for Surgery’ vs ‘Clearance’

Medical terms can be misleading at times. However, it is important to know the difference between these two declarations for pre operative examination: ‘Decision for Surgery’ and ‘Clearance’. Knowing the difference is very important when processing medical billings.

A part of this is because ‘decision for surgery’ visits are subject to additional fees by the surgeons. Unlike preoperative clearance, its fees are already part of the global surgical package. Codings will also help determine this easily in a patient’s medical records. An E/M code with a -57 modifier should be reported when the encounter happens on or a day before the actual date of surgery. 

Submitting Claims for Pre-Op Clearance

Before, insurance policies were used to deny claims with preoperative clearance and examination fees. This is because these examinations for pre-op clearance were tagged as ‘routine physical checkups’ which, as stated by law, is not necessary to be covered by insurance providers.

Luckily today, this was made clear to the practice. The central billing office requests insurance providers to pay for the pre-operative medical examinations as long as it’s proven to be ‘medically necessary. This claim should have the proper pre-operative ICD 10 code (Z01.810 – Z01.818) for pre-op examinations. Everything must be well recorded, including additional diagnoses and conditions that can affect the surgery and the patient.

Related: Step-by-Step Guide On How to Submit a Claim

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Pre-op clearance should be processed flawlessly, whether it’s in the documentation or in the operation side of things. Accurate document records are not only necessary but crucial to the overall success of the operation and the patient’s recovery. Medical billings must be properly attended to in order to ensure smooth operations for the healthcare provider and the patient.

For us at the MedCal Group, we believe that the key to a patient’s loyalty depends on their overall medical experience during treatment, which includes smooth processing of medical billings. To ensure that this department is properly attended to, you can always count on our medical coding services. Send us a message if you need more info.

References:

https://www.gafp.org/coding-pre-operative-clearances-correctly/

https://www.thedoctors.com/articles/why-medical-clearance-is-really-a-preoperative-evaluation/ 

The post Preoperative Clearance: The Correct Way To Code appeared first on MedCal Inc.

Insurance policies make it easier for everyone to afford their medical bills during emergencies. It’s always great to have one until you found out you need to go through the process of submitting insurance claims.

For claims processing to be successful, it needs to have steady and proper communication between you, your healthcare provider, and your insurance provider. To some, it’s an excruciatingly long process. But for others who know a thing or two on how to submit a claim properly, it can be more manageable.

Options For Submitting Insurance Claims 

Processing insurance claims for medical billings used to be a bother. Luckily, there are two ways of submitting health insurance claims:

1. Healthcare services that offer direct transactions to insurance providers/payers.
2. You fill up the forms and submit claims to the insurance provider yourself.

The pros of having your healthcare provider do it for you are mostly convenience. You don’t have to worry about filling up forms and running papers around since they can do the work for you. However, some healthcare providers also struggle when submitting insurance claims. When papers and billings get piled up, and there’s no steady process in place, your insurance claim can get denied constantly. Worst, you’ll have to wait for the reprocessing to finish for months (even years).

While receiving a notice that your claim is denied can be alarming, know that it can still be revised and resubmitted. If you can’t entrust this process to your provider, or you need to speed things up, try doing the processing yourself. It takes a few basic steps to submit a claim if you’ve already paid out-of-pocket. 

4 Steps To Submit A Claim 

Submitting claims to insurance is a tough thing to handle. But if you have a good knowledge of how it’s done, and what you should prepare for, it can help lighten the load. 

Here are the 4 basic steps you should know when submitting insurance claims:

Step 1 – Ask for an itemized receipt from your doctor/ healthcare service

Start with obtaining a list of items detailed in your receipt. Contact your doctor or your healthcare provider and ask for this. It should have all healthcare services provided, professional fees, and the costs of each. It should also have all the medications, treatments, and laboratory costs included in the list.

This part should be easy, all you need is to call your provider and tell them you need it for your insurance claim. Once received, double-check everything with your doctor/provider to make sure nothing is amiss.

Step 2 – Get your claim form from your insurance company

The next step is to ask your insurance provider for their claim form. If you haven’t processed a claim for a long time, there might be differences in the form provided by your insurance. So make sure you got the most updated form to avoid any delay.

This form is different with every insurance provider. This is because they also have different rules, metrics, and indicators depending on the policy they are offering. The more information you put on the form, the more it’s helpful for everyone. Also, make sure you understood the instructions and keep your details consistent with your account details. Some of these details would be:

• Your basic personal information (Name, Address, Date of Birth, etc.)
• Insurance policy details and account/subscriber number
• Reason for a medical visit, and other details about your illness and conditions
• Information of your healthcare provider, and doctor’s name
• All the expenses that you already paid

Step 3 – Make a copy of it (at least 1)

This is an important step that most people miss. Keep in mind that these documents involve three parties: you, your healthcare provider, and your insurance provider. You should make a copy of all the documents you have received from them to eliminate mistakes during medical claims processing.

If you know a thing or two about medical codes, you can also check for inconsistencies and ask your provider if there’s something that needs to be addressed. Make sure all the services, medications, and treatments are reflected in the codes.

Step 4 – Review carefully then send

Review everything before sending it to your insurance provider. Your aim is to achieve a clean claim for your claims submission. Call your insurance to let them know about your claims submission. 

Next is to submit all paperwork to your insurance provider. If possible, you can email or fax them these papers to speed things up. Take note that it can take up to 30-45 business days of processing your claim– you don’t want to mess this up and wait another 45 days. However, some providers have different timelines. It’s best to ask them via a call to know how long you need to wait.

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In comparison, it’s much easier and less of a hassle if your chosen healthcare provider does all the submission for you. However, it’s important to know that claims processing is a lot more complex from their point of view. Some of the steps above are also dependent on your healthcare provider’s skill in processing and coordination, especially on the consistency of your medical bills and records.

Healthcare providers need to have a steady system when it comes to claims processing and submission. As pros in the field, we at MedCal Group offer all the medical billing outsourcing help you’ll ever need for it. If you’re interested to know more, give us a call.

References:

https://www.internationalstudentinsurance.com/explained/claims-submission-in-detail.php

https://www.internationalstudentinsurance.com/blog/2013/09/step-by-step-guide-how-do-i-submit-an-insurance-claim

https://www.thebalance.com/if-you-have-to-file-a-health-insurance-claim-form-2645672

The post Step-By-Step Guide On How to Submit a Claim appeared first on MedCal Inc.

Medical records and papers can’t be simply done by anyone. People who process these papers need to have proper training and the right skill set for the job. This is mostly because they also need to have knowledge on the right medical coding terms.

These medical coding terms are standards in healthcare. It helps people within the medical and insurance fields understand diagnoses and treatments of every patient. 

Other healthcare providers even require medical call center agents to be knowledgeable on certain medical coding terms. This is because it can help them in assisting their patients better via phone. If you’re someone training to be a medical coder, or someone who needs to know about medical coding terms, these are the top things you should know.

What is Medical Coding?

It is the practice of using shorthand alphanumeric codes that represent every aspect of healthcare. Medical coding works much like a translation for medical practitioners to be able to quickly identify diagnoses, conditions, prescriptions, and all medical-related language at a glance.

Medical coders would take reports from physicians which will provide them with all the information about a patient’s condition, diagnosis, treatments and others. These records will be translated into codes to be submitted as part of a medical claim. These codes should be free from error which is crucial in achieving a clean claim.

Related: 5 Common Medical Billing & Coding Errors

Who Uses These Medical Coding Terms?

Medical coding terms are used by different people in the healthcare industry. These people are vital to ensure that procedures and processes go smoothly. These medical coding terms are most likely used by:

Medical coders

These people translate a patient’s medical records into a coded format. These translations help healthcare professionals and billing insurance understand and take in all information quickly. They make it easy for healthcare professionals to communicate with insurance providers. Without these medical coders translating codes, claims processing will be difficult and will take longer time.

Healthcare professionals

Physicians and surgeons need to have knowledge of these medical codes since they will be providing diagnosis and treatments to the patients. Medical coding terms provide vital information that translate any healthcare-related term into a language that can only be understood by people working in the medical field. This will also allow them to read diagnostics and procedures faster so they can act on treatments quickly.

Billing and insurance staff 

Medical coding terms are initially created to improve the process of claims submission for insurance companies. Staff who are responsible for medical billings need to have fundamental knowledge and skills needed to identify errors in the code. They also apply these codes to the patient’s bill to be submitted to the patient and his/her insurance provider for collection.

3 Types Of Medical Coding Terms 

Just like translating codes for systems to work on a computer, medical coding also has its own language types. These three are the most basic types of medical coding language:

ICD codes

An abbreviation for International Classification of Diseases, this medical code type are diagnostic codes that describe causes of every visit, may it be an injury, an illness, or death. Since the late 1940s, it has been updated a lot of times to adjust to the improvement of the healthcare industry and its systems.

To date, the tenth revision (ICD-10-CM) is currently being used in the US. Clinical modification or CM allows increasing the number of codes for diagnoses. It adds more codes per diagnosis to give coders more flexibility on the terms used, as well as it helps them to be more specific on the codes they use.

While ICD codes show a physician’s diagnosis, treatments, and patient’s condition, they are also used to determine medical necessity in billings. Some medical terms that uses ICD codes are the following:

• E-codes describe injuries that resulted from external factors rather than internal illnesses like car accidents, poisoning, or certain injuries.
• V-codes are used in case a patient received healthcare services for a specific reason like preventative care or monthly check ups instead of illnesses.
• NOS is also known as a ‘Not Otherwise Specified’ code, and is used if a healthcare professional can’t give a specific diagnosis for a patient. However, the doctor may still provide treatment based on the results.
• NEC means ‘Not Elsewhere Classifiable’ which can be used when there’s no code to classify a diagnosis. 
• Dx is the short term for ‘Diagnosis Codes’, and is used in reporting a patient’s history or billing information. 

CPT codes

CPT stands for Current Procedure Terminology which is a type of medical coding used to document all the medical procedures done. These codes are divided into three categories:

• Category I is a five-digit numeric coding that is divided into six ranges, namely: Evaluation and Management, Anesthesia, Surgery, Radiology, Pathology, Laboratory and Medicine.
• Category II is optional, but is used to correspond to how performance is measured. These are also composed of five-digit codes added to the end of Category I CPT.
• Category III pertains to all the medical technology used for the procedure and treatments.
• E/M Codes stand for evaluation and management which describes the healthcare professional’s evaluation of a patient’s treatment in order to manage their condition.
• Fee schedule are codes that provides the information on the cost of each treatment. This helps the billing staff to review billing information to make sure it’s accurate and error-free for the payers. 

HCPCS codes

Healthcare Common Procedure Coding System (HCPCS) in medical and healthcare lingo  is commonly pronounced as “hickpicks”. It is the official code that is set for outpatient hospital care and can include medications, drugs, and even Medicaid and Medicare.

This kind of coding type is divided into three levels.

• Level I HCPCS codes are CPT codes which pertain to the procedures, treatments and services performed by a healthcare provider to a patient.
• Level II is a set of alphanumeric codes that are separated into 17 sections based on area of specificity. It refers to codes that describe medical equipment, some medications and other out-patient services not found in the CPT system.
• Level III codes are specific to your location and are used to bill local insurance providers and entities.

HCPCS codes should correspond well with its diagnostic code in which the medical procedure is justified.

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Medical coding terms are a lot to take in, especially if you’re a beginner or a medical call center agent in training. For healthcare providers, it can also be a challenge to look for people who have the right knowledge for it. However, medical coding should be dealt with the highest priority as it is vital in processing medical billings and ensuring that payments are collected on time.

Medical billings are essential to any healthcare business. If you need an extra helping hand to secure your medical billings, you can always trust MedCal’s expertise. We offer medical billing services perfect for any healthcare business, big or small. Send us a message to inquire!

References:

https://www.medicalbillingandcoding.org/learn-more-about-coding/

https://www.indeed.com/career-advice/career-development/medical-coding-terminology

https://www.abetteranswer.com/blog/important-skills-that-every-medical-call-center-agent-should-have

The post A Beginner’s Guide To Medical Coding Terms appeared first on MedCal Inc.

Medical billing is as complex as it gets. While it is ideal for every healthcare provider to process and submit claims error-free, compliance issues and other inappropriate practices are sometimes missed. In this case, medical billing audits can help.

Medical billing audits help identify which areas in medical billing collections need attention and improvement. A healthcare system should know how to run these audits regularly to provide quality care to their patients. Doing so can also aid in achieving clean claims faster.

What is a medical billing audit?

A medical billing audit is an organized process that inspects, evaluates, and analyzes if the documentations are reliable enough for medical billing processing. 

It runs quality checks through patients’ health records, medical codes, and other medical billing data that are submitted to insurance providers. This is done to ensure that the processes in medical billings comply with the rules and are free from inappropriate billing practices. 

Any aspect in the medical billing collection process affects its overall results. May it come from an honest mistake, or a result of a minor non-compliance issue, it will most likely be considered as a bad claim. There are two types of medical billing audits:

• Prospective audits – These audits are conducted before claims are submitted to payers. This type of medical billing audit focuses on reviewing targeted cases which are often selected based on Office of Inspector’s (OIG) guidelines.

• Retrospective audits – This is the type of audit that reviews claims after it was submitted. Preferably during adjudication, the claim was considered either paid, denied, or pending. Retrospective audits run a deeper look on the internal claims processing to identify problem areas.

8 Things to Consider When Running an Audit

Billing audits ensure quality and hassle-free claims processing. While it involves a series of strict and detailed compliance, it is necessary for everyone involved in the medical billing process. Running a medical billing audit usually comprises these 8 key steps.

1. Are patient records verified?

It’s vital to begin with the patient’s details first. Records should have a verification of the patient’s valid IDs, and authorizations, if applicable. Patient should be able to provide updated information about his/her common details, such as name, date of birth, date of visit, place of service, and others. 

These details should be placed in the demographics chart to be matched with its corresponding claim documents. Here, accidental switches can sometimes happen. It’s important to check if the claim demographics and data is the same with that of the patient’s medical records.

2. Is the provider information updated?

Details of the healthcare provider must be updated and accurate. It’s very crucial that the provider indicated in the documentation is legally licensed and has the right credentials approved by the state. 

3. Are the records accurate and don’t have duplicates?

Sometimes, duplicate records are attached by mistake. It should be properly checked and inspected to avoid future errors and back-and-forth filing. History of paid and denied claims from a specific healthcare provider with the same date of service, medical codes and bills must also be verified.

It should also follow that codes must be identified too. Everything must be checked and scrutinized during the audit— Like, which codes were paid or what were denied in the previously submitted claims? Are the records the same, or do they have additional details? Has the provider split the bills into separate claims? 

4. Are medical history and number of visits accurate?

Chronological records of events that happen every visit should also be accurate during audits. There should be records in the documents that show every patient encounter, physical examination, and succeeding check-ups. 

It should provide detailed, valid, and legible entries that discuss the findings of the physician in service. It should also have a list of the patient’s health problems indicated in their records. Everything must be properly documented, including referrals to other departments to prove that there is proper coordination in the practice. These should also contain the date of service, with a summary of visits.

5. Is the diagnostic report factual?

Once all the above details are verified, diagnostics should be checked and inspected as well. From blood works, examinations, and other laboratory tests, everything must be documented and verified. 

Certain reports like radiological tests will only be completed upon image interpretation, and must be authorized by the professionals. All results must have corresponding dates and must be legally authorized.

6. Does the report match with diagnosis and treatment?

As follows, diagnosis and treatment should be able to match the diagnostic report. This part is one of the most crucial areas since the final diagnosis forms the basis of the treatment plan. 

Treatment plans should be consistent with the patient’s diagnosis and must include in the records a summary of reports from consultants, lab technicians, and imaging or scan interpretations. These data should be able to match the attending physician’s findings and recommended treatments.

7. Are the prescribed medications valid?

Next is to validate if the medical prescriptions given are valid. Documents should have a record of medication and drug prescriptions, including refills, if necessary. For medical devices prescribed, this should also be verified with the attending physician.

Confirmation of these documentation must also include the patient’s education on the recommended medications. Patients must be given the proper instructions on doses and intake and should be monitored in the report.

8. Did they use the right code formats?

Last but not the least, and probably the most crucial of all, is the inspection of medical coding. Coding compliance must be verified and scrutinized to avoid any mistakes. Medical billing audits also suggest checking if CPT/ICD codes are used properly. 

Modifiers used in coding play a big role in the medical billing process. It should be inspected and evaluated to avoid the risk of errors. Perform a cross-check with the bills and codes assigned and see if there are unlisted codes, wrong codings, upcodings, and others.

What are the benefits of a medical billing audit?

Running audits on a regular basis can improve how you do processes in your practice and minimizes claim denials. While there are no rules that oblige you to run them every now and then, health providers are seeing its benefits in their overall performance. 

Here’s why you should conduct medical billing audits:

• Error-free claims submission means faster payouts, which also means more profit to your practice.
• It helps you manage your operations and processes, and find out what needs attention and guidance.
• It provides your staff with an opportunity to correct mistakes before it gets worse.
• It protects your practice against fraudulent claims and other compliance issues.
• It prevents you from making mistakes that may sometimes cause you money.

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Trust that in MedCal, we make sure that the entire billing processing is smooth, fast, but completely error-free. We conduct regular medical billing audits to ensure factual, accurate, and faultless medical billing collections and processing. Talk to us today!

The post A Guide On Medical Billing Audit: 8 Things To Consider appeared first on MedCal Inc.

There’s nothing that can ruin a patient’s recovery than a medical bill declined by their own insurance. Insurance denial may look like an issue between the patient and his insurance provider, but health organizations hold the bigger piece of the pie.

Claims processing has always been a tedious process in any healthcare organization. Without proper process and error-free procedures, clean claims will always be difficult to achieve. Claims denial can be a challenge to deal with, but systems inside a healthcare institution highly depend on it.

Common Reasons Why Insurance Claims Are Denied

Poor claims management affects the financial health, operations, and dignity of a practice and the people behind it. Insurance denial is more likely a product of faulty processing. From the registration up to claim submission, all processes involved must be smooth, timely, and error-free.

Here are the most common reasons why an insurance claim is denied:

1. Missed filing deadlines

There are a number of reasons why filing deadlines are missed. Insurance providers have different sets of timelines and sometimes it can get confusing during claims processing. Some payers are generous enough to wait 90 days to a year from the date of service, while some can only hold up to 15 to 30 days.

Organizations with unstable claims management systems tend to miss deadlines more frequently. Issues about incomplete documents, lost papers, missing bill reports, and other administrative tasks can get lost in the piles. While these can easily be corrected, some simply failed to make it on time.

2. Invalid subscriber identification details

Sometimes, errors were unconsciously made at the beginning of the registration process. This can lead to inaccurate data or incomplete subscriber identification details. For example, the patient handed an old ID number, or their information wasn’t updated. Other times, staff members failed to manually input the right information due to distractions during data collection. Honest mistakes like this can be grounds for outright insurance denial.

Advanced systems can pave the way to a better data collection process. It’s ideal for health providers to come up with technologies to avoid simple human errors. It’s also important to note that delegating processes like this to trained and responsible staff members is key to achieving clean claims.

3. Duplicate claims

Healthcare Finance News found out that healthcare providers are the biggest cause of claim denials, more than insurance policies and medical conditions. Among its mistakes are simple administrative mishaps, and one of them is submitting duplicate claims.

These accidents usually happen due to lack of steady systems in the practice. An admin staff would sometimes resubmit claims before an insurance company responds to the first submitted claim. Tracking workflows, updating status, and a steady system should always be in place when running financial processes like medical claims filing.

4. Faulty coding 

Coding languages change from time to time, and while medical practitioners adapt to these changes, errors can easily be made. Providing a modern technology system that would minimize human intervention can be the best way to deal with this. Clinical knowledge base must be updated fully to avoid potential problems during claims processing.

Faulty coding also happens when modifiers are incorrectly used. Medical coders and staff who facilitate this process should be well-trained on the use of appropriate modifiers. They should also be given proper tools that would help them finish the task faster and most importantly, free from errors.

Related: 5 Common Medical Billing & Coding Errors

5. Medical necessity issues

In some cases, the insurance or payer believes that the requested service is not medically necessary for the subscriber. While it can be true in some cases, this can also be the result of incomplete documents and data that can support the level of medical necessity.

Additional documentation is usually requested for this. Health providers should have an integrated EHR and PM platform for a more efficient charting and speedy access to the documents needed. While platforms are considered a best investment for this, they can also cost a fortune, especially for small and starting healthcare providers.

6. Services are not covered by the plan

There are a number of reasons why a certain service can’t be covered by the plan. However, it still falls on the biller’s responsibility. Healthcare providers should be able to differentiate what is considered valid in the insurance policy and communicate it to the patient beforehand. They should be able to read and understand different insurance policies and plan inclusions to make it easier for all.

Some common cases also include failure to correctly classify the service requested under screening studies or lab tests. Some lab tests for example, were incorrectly listed as screening studies which, in the payer’s point of view, can’t be accepted as valid. Billers should have staff members who know how to differentiate these services on a case-to-case basis.

7. Data discrepancies

One of the simple and most common reasons for claim denials are data discrepancies. This could be the result of a wrong registration, improper use of codes, or incorrect patient information. For one simple mistake of identifying a patient as a male, if the requested medical service is only applicable to females, this will automatically deem the claim denied.

Systems and platforms should be put in place to avoid claim billing errors, but it should also be guided and managed by a trained staff. There will always be flaws in the system, and a medical staff member must be able to identify these errors before submission. 

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This may be a hard pill to swallow, but not all healthcare providers and organizations are ready to face these medical billing issues, especially when it comes to claim denials. Sometimes, it’s best to leave it to people who can focus on these processes entirely.

When it comes to medical billings, is it worth it to invest in costly systems, staff hiring and high-quality training, when all you need is a service that can handle all your medical billing needs? If you’re interested to know about our denial management in medical billing and other services, schedule an appointment and we’ll be happy to walk you through.

Resources:

https://www.aafp.org/pubs/fpm/issues/2015/0300/p7.html

https://www.carecloud.com/continuum/3-common-issues-that-lead-to-insurance-claim-denials/

The post Why Is A Medical Insurance Claim Denied? appeared first on MedCal Inc.

Every health care organization’s revenue relies on medical billings. This is why its whole procedure from start to finish is crucial. Without the right knowledge on how to find a healthy system for it, everything else in the medical organization will suffer. 

If you’re someone from a healthcare organization, or a patient who’s curious about what is a medical billing process, read on.

How Can A Medical Billing Process Affect Your Revenue?

There are a lot of ways to answer this, but the simplest one is this: medical billings, if not properly done, can disrupt any essential medical practice and system. By affecting an organization’s revenue cycle, smooth-running operations and procedures can go to shambles because of fund shortage. 

Processing medical billings is one thing, perfecting the process is another. It’s not enough to just delegate anyone who can do the paperwork for it. Since the right process includes knowing specific medical codes, you’ll need a bunch of skillful professionals to run it. 

Other things that you also need to consider are:

• The complexities of insurance policies and each patient’s plan inclusions.
• Timelines of processing for different healthcare insurance.
• The intricacies of the collection process for every type of insurance.
• Recording and coding process with quality checking
• Compliances and rules to follow
• Re-processing and checking of errors once claim is denied
• The right technology and systems to use

These (and maybe a lot more) can affect the collection process in medical billing and overall revenue cycle. It can be a handful for some, considering that healthcare procedures and systems can also be at risk. But there’s still a better way to breeze through it– finding the right medical billing service provider to do it for you.

8 Basic Steps In A Medical Billing Process

All third-party patient statement services know the best way to do this. But if you prefer to do this in-house, you should be able to know the basics. We’ve summarized these 8 basic steps to get you familiarized. 

1. Patient registration

This key step allows the healthcare provider to collect details from the patient. Once a patient calls for a doctor’s appointment with a healthcare provider, certain forms will be filled up for records. Upon their arrival, all primary details like name, date of birth, reason of visit will be asked by a representative. Asking about insurance should come in next, and should ensure that a patient is eligible for the service.

2. Financial responsibility

This step informs and confirms the patient about the details of their insurance coverage. This is where a medical staff will determine which procedures and services will be covered during the visit. 

This also includes knowing what type of coverage the patient’s insurance has and the plans the patient is eligible to use, while communicating it entirely to the patient. This is to help the biller identify if the patient is aware of the fact that if some of the billings are not covered by their insurance plan or policy, he/she should be able to pay for the costs. 

3. Check in and check out

These are two vital steps that are done every time patients visit a hospital. Upon patient check-in, the biller should be able to have them fill up forms (for first-timers) or update their existing records. IDs will also be asked to confirm the identity of the patient, and if applicable, their insurance card

At the time of check-out, reports will then again be recorded and sent to the medical coder. The medical coder then translates this information into a medical code that applies to the patient’s diagnosis and details. This is called the ‘superbill’ which is typically transferred through a software for the medical biller to work on.

4. Superbill creation

Once the medical coder is done, the superbill is ready for processing. The superbill will be transferred in paper claim form, or a billing software, whichever the health care provider uses. This step also indicates the costs of the procedures, and states it in the claim. These costs only include the bills that are applicable to the patient’s contract with the insurance provider.

The superbill also needs to be checked for compliance in terms of coding and format. All details should be accurate, as well as their corresponding codes.  The medical biller coder are both responsible for this part of the process. Demographic informations, medical history and procedures usually follow the CPT or HCPCS codes. Each procedures is also paried with a diagnosis code (ICD code). Provider information is also listed using a National Provider Index number (NPI).

5. Claims submission

Then comes the most exciting part– the claims submission. While all preparations were made, it’s important to keep an eye on this process. Certain rules from the Health Insurance Portability and Accountability Act of 1996 (HIPAA) required health entities to submit claims electronically, except in certain situations.

This was strictly implemented because manual claims have high error rates and typically takes a long time to accomplish. However, the downside is that not all small and starting healthcare providers have access to the right software or system. If you’re one struggling with this, it can be easily solved by hiring third-party patient statement services or a clearinghouse to make the job easier.

6. Monitoring of claims during adjudication

Once an insurance receives the claim, it’s bound for adjudication. This process constitutes how the payer (insurance company) evaluates a medical claim and decides if it’s valid, and is compliant of all the rules. All the processes before adjudication will be evaluated and checked for the payer to decide if the claim will be accepted or denied.

A claim will be denied if the payer discovers an error, is not accurate with different details, or there are misplaced and misrepresented codes somewhere. Once denied, the payer returns it to the biller to correct it again and resubmit. In this part, submission and re-processing can be really tiresome and can take too much time. 

However once everything is in place, a report will be made by the payer discussing all the costs they’re willing to pay. For claims that went through this process unscathed and free from error in the first submission, they are referred to as ‘clean claims’.

7. Generating patient statements

The next process is generating patient statements after the report is made. This will indicate all the remaining costs the patient has to pay. The biller also provides an Explanation of Benefits (EOB) to the patient. This is preferably the easiest way to discuss to the patient what procedures are included in their plan’s coverage.

8. Patient payment collection and follow-ups

Most commonly, the last of this process is the least favorable of all– the collection process in medical billing. If a patient is delinquent on their bills, you or your outsourced medical collection agency needs to have a steady system to make sure payments are collected. It’s the responsibility of the medical biller to follow up consistently in order for the bill to be settled as soon as possible.

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While there are a number of ways to take care of an entire medical billing process, it takes a steady system to support it. A healthcare provider that performs the best medical billing process can reap all the benefits. For those who are still struggling with this however, there are people who can and willing to help– like us, at MedCal. 

If you need to know more about our medical billing services, feel free to schedule an appointment with one of our representatives.

Resources:

https://www.pettigrewmedical.com/the-key-steps-to-know-for-successful-medical-billing/

https://www.medicalbillingandcoding.org/billing-process/

https://www.bryantstratton.edu/blog/2018/january/medical-billing-process

The post Steps To A Successful Medical Billing Process appeared first on MedCal Inc.

While medical practitioners and caregivers are considered the most vital components of a medical institution, their work is highly dependent on administrative processes. Skillful backend office staff make up a relevant portion of the workforce in the hospital. They keep operations and day-to-day medical documents in check, including the responsibility of medical billings.

Inhouse staffing can do a lot for your business, however, it stays as a traditional and long-term option. When huge workloads are imminent and staffing sources are a big problem, you shouldn’t let your staff and business suffer. Maybe it’s time for you to widen your horizons– Outsourcing your medical billings and processes can be your best bet.

Why outsource your medical billings? 

We can’t think of any reason why you shouldn’t let medical billing companies handle your medical bills. If you’re not aware of any, or simply not convinced, here’s to help you decide.

1. You’ll have full control

Most fear that once they start outsourcing their medical billings, ownership and control will be compromised. But that’s nothing but a misconception. As a matter of fact, outsourcing medical billings puts you in better control of your business processes. 

Since medical processes are being handled by experts who are dedicated to process billings for you, you don’t have to manage billing issues that are not worth your time. You’ll have full control over your operations, and staff hours will be allocated to other needs of the business.

2. It’ll cost you less

Yes, you will have to pay for a third-party service, but in retrospect, this can cause you a lot less. Processing your medical billing inhouse may mean hiring more staff when the workload gets heavier, having to work on its software and hardware (including maintenance), staff and personnel salaries, and costs of office and medical equipment. 

Outsourced billing services can maximize your money. A one-time upfront cost of a billing service takes away the stress of managing billing issues and lessens valuable staff hours. Also, these third-party billing companies handle a lot of private practice billings that you don’t have to shoulder all the software and hardware costs and maintenance fees yourself. 

3. Transparency and safety

Medical billing outsourcing may look like you’re entrusting your business processes to complete strangers. This may be true at some point, however, as a client, you have all the right to look for the best billing company that supports your needs and suits your preferences. Billing companies know this too, which is why their main goal is to maintain your trust in them. 

Most established billing providers secure transactions with HIPAA-compliant credentials while safeguarding their database from hacking attempts. With the amount of billings they process, these providers have secured their infrastructure and worked on their security to avoid any issue. Expect that they will be transparent and will always keep you in the loop of things about your account. They might even have set certain metrics just to earn consistent positive reviews from you.

4. Faster payments

The best thing about outsourced billing services is that it provides you professional service of handling billing processes. When medical billings are processed better, there will be little room for errors, and will speed up the approval from insurance companies.

Outsourced medical billing companies also have set their workflows in accordance to processing needs. Every transaction will be smoother and error-free, without you having to worry about anything.

5. Stress-free work environment

The medical field is not spared from the ‘Great Resignation’ bane. Medical practitioners and staff demand proper environment where they can thrive in their careers. Medical billings can be an important process of the business, but no one who’s in medical practice has ever dreamt of filling out paperwork and chasing insurance companies in their career.

By outsourcing medical billings, you’re freeing up your staff from the stresses of billing paperwork. Letting them focus on patients keeps it their priority, which keeps them invested to their work, and happier with their career. You won’t have to worry about hiring dedicated medical teams or admin staff either because these things will all be covered by outsource companies.

6. Lesser billing errors

Medical billings need precision and accuracy, and requires perfection in all aspects. There shouldn’t be room for error or your revenue will suffer the consequences. One tiny mistake can lead to delayed payments and disruption of medical processes. It’s no surprise to know that in medical billings, mistakes can be costly.

Which is why, if you don’t have time (and budget) for mistakes, it’s best to take it to pros. Outsourcing medical billings helps your business be more profitable. With you focusing on the most important aspects of business and your patients, you’re also assured that your cashflow and business revenue won’t be compromised. 

Related: 5 Common Medical Billing & Coding Errors

7. Adherence to changing regulations

Rules of healthcare change every so often that it’s difficult to keep track. New protocols are set, and if you’re not aware of it, mistakes will be inevitable– And you know you can’t afford to make mistake when processing medical billings.

Outsourced medical billing services are always on top of these changing rules and regulations. This helps them submit clean claims to avoid denials. This is also one of the reasons why it’s better to entrust your billing processes to them.

8. Expert-level transactions

Everything is complex when it comes to medical billings. While you can train a person with no medical background to handle it, there will be scenarios or questions that only someone with a steady set of skills can answer. If the one handling this is not knowledgeable enough, mistakes will continue to be made, and claim denials will be certain.

Service providers only have well-trained staff to answer even the most complex of questions about medical billings. Outsourced medical billings will have greater chances of staying up-to-date with processes and rules to be able to produce clean claims. Teams with top skills and knowledge comprise their organization to keep mistakes from occurring.

9. Scalable business growth

Billing companies outperforms private practice by 15% when it comes to processing medical billings. Better performance and results is best for the revenue and cash flow of any medical organization.

With lesser interruptions in your daily operations, complications will also be reduced, allowing you to focus on scaling you business and taking care of clients. This is recommended for businesses of all sizes– whether you’re a big player wanting to specialize on something, or a small and start-up aiming for growth. Your revenue lies on bills payment, and if that’s as important as your business’ success, you shouldn’t be scrimping on that.

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When the going gets tough, you should be able to find better ways to deal with it. Outsourcing medical billings might be the missing link towards your organization’s success. If you need to see how it can help you further, allow us at MedCal to walk you through our top-notch services.

References:

https://www.flatworldsolutions.com/healthcare/articles/reasons-to-outsource-medical-billing.php

https://education.ncgmedical.com/blog/10-reasons-to-outsource-your-medical-billing

The post Outsourcing Medical Billing: Is it Worth it? appeared first on MedCal Inc.

Clean claims are important to the revenue and cash flow of any health care business. Submitting a clean claim is vital in processing payments for medical treatments, securing approvals from insurance companies, and making sure all elements involved in the healthcare system are sufficiently and timely funded.

It is important to note that there are three parties essential to the revenue and cash flow system of medical billings and clean claim submission. These three parties are: the patients, the health care provider (biller) and the insurance company (payer). Clean claims involve documentations and processes that connect these three parties together.

What is a clean claim?

A clean claim refers to a submitted medical claim free from any error, mistake, and issues that can result in payment denials. It is composed of all documents, records, and necessary forms and details about medical procedures and treatments. These documentations are completed and submitted by the biller (health care provider) for payment processing by the insurance company (payer).

Several elements are required to create a clean claim. These elements are vital factors for timely processing of payments. All these elements must be complete, factual, and accurate with the patient’s details and healthcare needs.

What would be considered a clean claim?

So what exactly should a clean claim look like? There are comprehensive rules and discussion points that constitute the entirety of its details. However, here are the most common attributes of what a clean claim should be:

• A clear identification of the health facility, the health professional/s involved, medical equipment and providers, and other identifying numbers
• It should identify the patient’s information (full name, address, date of birth, etc.) and their chosen insurance plan. The plan’s coverage must also be in effect during the time the medical service was provided.
• The claim should also identify the payer’s details, including the payer identification number, mailing address, group number, etc.
• The healthcare provider/professional should have a valid license to perform the services, should be clean from fraudulent acts and accusations, and isn’t under investigation.
• Every medical procedure and treatment done to the patient must be in coded format. This also includes the coded diagnosis supporting the treatments provided. All codes and modifiers should be free from errors and are not expired, deleted, or inaccurate.
• No questions or potential issues are identified regarding the medical necessity. If necessary, it should also have detailed documentation about the appropriateness of the medical service provided.
• If authorization was required for certain medical treatments, it should also have the necessary details.
• It should have all documentations and records of the services provided as required by the health plan.
• A clean claim must be finished and submitted timely, and within the given time filing window.

Clean claim vs dirty claim

Even without a medical background, one can easily tell these two apart. Clean claims are identified as claims that were accepted and paid the first time they were submitted. These are the claims that were never rejected because they were ‘clean’ and error-free.

Dirty claims, on the other hand, are claims that were filed more than once or maybe a couple times. These usually contain errors and have been denied, but can still be fixed and resubmitted for processing. Dirty claims can delay payments, trigger operation issues, and disrupt a healthcare business’ cash flow and revenue cycle.

6 Tips on how to submit a clean claim and lessen denials

Preparing and submitting a clean claim is easier said than done. Prepare yourself and be aware of the things you need to do during this process. These tips might help:

1. Keep patient details updated

Whether you’re using a system for documentation purposes, or doing this the traditional way, it’s important to keep your files and patient details updated. Automate reminders, send monthly emails to your patient database, and make sure every patient visit is being recorded. This can save from all the hassles of chasing and verifying simple information from a patient while on a tight timeline.

2. Run eligibility verifications prior to date of service

Outdated insurance information can disrupt overall processes and your cash flow. It’s important to secure information from established patients whenever they go visit your practice or your healthcare institution. Verify if all insurance details are up-to-date, especially the type of plan and coverage.

3. Detail all documentations

Proper documentation must be handled meticulously to avoid claim denials. Make sure that all procedures, treatments, medications, equipment, and diagnosis are detailed and completely accurate. Some would even secure video or audio recordings to make sure every information in the document is factual and supported by evidence.

4. Verify and double-check codings

Check and recheck medical codings to ensure that all modifiers apply to their corresponding procedures. If you still don’t have the time and proper personnel to do this, you can opt for third-party professionals who offer claims scrubbing. These codes are crucial to your claim’s approval or denial.

5. Stay on track of filing timelines

While having a clean claim requires you to keep your documentation perfect for payment approval, it also requires you to submit claims on time. An error-free claim won’t be of any use if you failed to submit it on the given filing time window. Pay attention to other factors that might cause delays, especially on issues associated with the patient. 

6. Hire a pro

Dealing with claims and preparing a clean claim in medical billing might be weighing you down at the moment. While there are other important things to take care of, clean claims are necessary to keep your cash flow and revenue from struggling. You can always choose to hire professionals, if it means lesser stress, bigger savings, and top-quality results for you.

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Medical billings and its processes always need your full attention. The wonders of automation may give you an easy fix from all these, but it can only do as much. Clean claims need to be done by able hands and minds to make sure every issue, process or problem is given proper attention and necessary actions. 

If you’re someone needing help on this, we got your back— send us an inquiry and let’s talk.

References:

https://revcycleintelligence.com/news/clean-claim-write-off-metrics-key-to-diagnostic-provider-success

https://www.magellanprovider.com/media/11924/f_cleanclaim.pdf

The post What is a Clean Claim in Medical Billing appeared first on MedCal Inc.

When it comes to medical billing, there are certain processes that shouldn’t be overlooked. One of them is the Revenue Cycle Management, also referred to as the RCM. This is one of the most important processes in the healthcare industry and is in fact considered the backbone of any healthcare institution.

Apart from recording each patient’s medical issue, medical billing needs a process that keeps track of revenue to make sure operations are in tune with the finances. This process unifies the business and clinical side of things through accurate data recording. This is also done to ensure that while patients are given proper care medically, all business processes, medications, equipment, supplies, and insurance are also taken care of.

Why Revenue Cycle Management (RCM) in Medical Billing is necessary

Medical billing is a complex process, and Revenue Cycle Management keeps these complexities at bay. The RCM in medical billing takes care of the cycle that involves the administrative work that connects finances to their corresponding clinical processes. This revenue cycle motivates both the doctors and patients who take part in the healthcare delivery process.

There are both internal and external factors involving the RCM that can affect the medical billing. Some of the most common are:

• Legislative mandates – Medical institutions need to follow certain procedures by law for it to become profitable to support the care delivery process.

• Contract changes – Most of the time, insurance policies keep changing and this can affect the patient’s financial statements. 

• Inconsistencies in data and records – With inconsistent records, there will be higher chances of denial from insurance companies.

• Denial from insurance companies – Once denied, another tedious process of following through, checking out discrepancies, and informing the patient can eat away time and energy.

It is also important to note that the RCM in medical billing needs to be handled by professionals. Though it may seem like administrative work, these processes, terms, and coding make it harder and impossible for an untrained personnel to deliver it properly.

Steps in the Revenue Cycle Management Process You Should Know

There are 7 key steps in an RCM billing process. It’s helpful to familiarize yourself with it so you can avoid any struggles in the future. 

1. Getting an RCM software, or hiring a medical billing and coding company

Should you purchase an RCM software for in-house work, or let third-party professionals take this extra job off your shoulders? The answer is clearly up to you. Decide which best fits your current goals, operations, and personnel availability. 

While it’s cheaper to get an RCM software for this process, it’s smart to seek help from third-party professionals who already know everything about it. Buying the software, hiring people to run in, training and delegating can exhaust your time and energy. It’s logical to hire skilled medical billing experts and save yourself from the hassles of it all. 

2. Patient registration and pre-authorization

This typically begins when a patient contacts a provider and sets an appointment. Relevant patient information will be asked and recorded in this stage. The physician’s office gives approval of treatment, medication, procedure, or use of equipment necessary for the patient’s medical needs. 

Pre-authorization happens when the insurance company decides which of these procedures, treatments and medications are covered, depending on the patient’s contract or policy. 

3. Charge capture and coding

This step can either be automated, or done the traditional way. With automation, information is instantly generated based on the providers’ documentation. For those with a traditional setup, a front desk staff would manually key in the information or send it over to billing.

Coding makes it easier for medical practitioners to know the diagnosis and treatment of the patient in one quick look. This is done by translating all procedures, diagnosis, medications, and treatment into codes that can only be performed by skilled medical coders. The codes should follow the set of standardized rules, at the same time it should concur with the CPT guidelines and the updated ICD-10 coding system.

4. Deductibles and copayments

Most insurance plans have deductibles and copayments as part of their policy. Deductibles in payments can only be availed if the patient has paid its premiums to the insurance company as part of the agreed plan or policy. 

Co-payments are the amounts and charges that can’t be covered by the insurance company. At this stage, patients should be made aware which of the treatments are deductible and which should be paid from their own pocket.

5. Submission of claims

Once every file is in its proper place, the next step is the submission of claims. Flawed, inconsistent, and incomplete documents can be reasons for insurance companies to deny your claim. This is why it’s vital to make sure all records and data are at par with the insurance company’s standards.

Cleaning everything out before submitting a claim, also known as ‘scrubbing’ is the best way to avoid claim denials from happening. At this step, the biller should keep an eye on the acceptance or denial of the claim.

Related: How to Improve Your Medical Claims Billing Process

6. Remittance processing

Once the patient’s claims are submitted, remittances will be sent back to them. Deductibles are determined, as well as co-payments but the biller and insurance provider can still negotiate the terms of the contract to ensure that policy coverages are maximized.

At this step, it’s also important to note the fee schedules of the billing provider. They should make sure that fees are up-to-date and that payments are given on-time. There are a lot of things that can affect the RCM during remittance processing. That’s why it’s crucial to have a steady system in place, as well as experts handling the job.

7. Denial management and insurance follow-up

There will be instances that payments will be denied. This is caused by inaccuracy of submitted records, or faulty codings. Once denied, this should be fixed and resubmitted for processing as soon as possible.

Insurance should also be followed-up for late payments, or fees that are only partially paid. Check in the accounts receivable (AR) if there are unsettled payments under the insurance company. It’s important to follow them up at once to avoid late settlements.

8. Patient collections

The last and the hardest part of the RCM is collecting payment from patients. Aside from setting up statements delivered via mail, it’s also important to have a dedicated person who can talk to patients about it when they are in the office. 

To prevent backlogs of these collections, it’s helpful to have automated systems that tell patients to settle their fees within a specific timeframe. Like sending them statements every end of the month, or giving them deadlines with late payment charges as penalties.

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It’s a tough job to keep track of all these things while running a big (or even small) healthcare organization. However, not having the right revenue cycle management (RCM) process can result in revenue loss which can disrupt your overall operations flow. 

To make sure everything in the medical billing section is well taken care of, you can take the easier path and have third-party experts like us handle all your RCM medical billing for you. Talk to us to know more.

The post Revenue Cycle in Healthcare: Management Process in Medical Billing appeared first on MedCal Inc.

For a healthcare system to be efficient, it has to have clean processes to ensure that medical health providers, staff, medicines and drugs, medical equipment, insurance companies, and many others are well taken care of. 

For beginners, processing medical bills can surely get a little confusing. With forms, fees, and back-and-forth filing that can go on for days (or even months), it’s important to keep yourself guided on the basics. Here’s an easy guide to medical billing and coding for dummies.

Medical billing explained

Simply put, medical billing involves filing and generating claims and submitting them to insurance companies for processing. This is done to provide payment or financial coverage for medical procedures and treatments for eligible patients.

Smoothing out medical billing processes helps keep medical treatments and procedures carry on without delays. It also keeps patients on track of their medical fees, and provides assistance to insurance companies to process claims faster.

Proper medical billing transactions can also help medical institutions and practitioners stay transparent and ethical to the market they serve.

Steps to follow in processing medical billing and coding (for dummies)

Still don’t know how to start your medical billing and coding process? Don’t worry, we’ve got you covered. Follow these ten steps for easy and hassle-free processing. 

Step 1 – Registering the patient

Collecting the patient’s basic information and reason of visit happens at the start of the medical billing process. Knowing the demographic details such as age, gender, address, and mobile number are the common things a patient is asked. For insurance companies, patients may also be asked to provide the following information:

• Insurance company and plan
• Policy ID/ number
• Name of policy owner/ insurance holder

These details give medical billers the authority to verify a patient’s details to support their claim submission. These details will be recorded so that patients won’t have to provide them again on their next visit. However, all details must be updated accordingly to avoid future problems.

Related: 5 Common Medical Billing & Coding Errors

Step 2 – Verifying insurance coverages and other fees

Next is determining the patient’s financial responsibility through insurance coverages. In this step, medical billers verify if certain medical procedures, illness and treatments can be covered by the patient’s insurance plan.

This stage also includes checking the terms of the patient’s eligibility and insurance plan coverage, which is most commonly referred to as the ‘superbill’. If there are procedures, treatments and other billings that can’t be covered by the insurance claim, including other accumulated expenses, the patient will be told to handle them financially.

Step 3 – Meeting with the healthcare provider

Most commonly known as the term ‘Encounter’, this stage is where the patient will be told to explain his/her medical conditions, symptoms and other medical problems. This is recorded via video or audio to ensure that all details are accurate during the processing of the claims.

Step 4 – Medical transcription and detailed verification

The recorded video or audio will then be listened to by a qualified personnel and verify if the information is accurate with the medical script. This is one of the most crucial parts of the medical billing process, inconsistencies are meticulously studied and verified to ensure everything is error-free.

Details will then be transferred into a transcripted and editable file version of the recorded audio or video. Any mistake during this step can affect the patient’s medical records, history and decision-making which can sometimes result in rejection of claims.

Step 5 – Coding and claims generation

Medical coding is done by converting all the transcripted information into medical codes. This makes the patient’s diagnosis, procedures and treatments easily understood by medical practitioners without having to read through the whole transcript.

Diagnosis and treatments are converted into medical terms and jargons unknown to non-medical practitioners. Coders use CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) codes to be transferred to the insurance service for payment.

Step 6 – Charge entry

The medical coder would calculate all the expenses included in the service. In this stage, all records are monitored with accuracy and charged according to its proper value. These charges will be claimed by the medical billing company to the insurance company for fund reimbursement. 

The medical practitioner will come up with a claim sheet and check if the values and the amount of all expenses incurred are correct. This sheet  is commonly composed of the following details:

• Patient’s details and basic information
• Patient’s medical history
• Codes of procedures done
• NPI (National Provider Index) number and insurance provider
• Place of service code

Step 7 – Submitting claims or ‘adjudication’

After ensuring that everything in the claim sheet is factual and accurate, it’s now ready for submission. Files and data will be electronically transmitted through EDI (Electronic Data Interchange) to the insurance provider, which is also referred to as ‘Charge Transmission’.

EDI can only allow clean claims to be transmitted. These claims must be free from errors which may include:

• Scrubbing- this happens when there are mistakes in the mandatory fields
• Invalid information- EDI will reject the claim if there are inconsistencies in the patient’s record
• Payer-related problems- happens when the insurance guidelines aren’t met, or there are problems in the payer’s details

Step 8 – Managing claim denials

Since claims submission is a very meticulous process, there are many instances that claims get denied or just partly accepted. This is why this step is a key factor in reducing denials with insurance providers. This stage involves constant follow-up and taking immediate and appropriate actions to ensure that all factors that resulted in claim denial are determined and analyzed.

Prioritizing the study of denied claims hastens the reprocessing to ensure maximum reimbursements. The team or medical practitioner assigned to this step will have to list down rejection issues so they can be prevented in the future.

Step 9 – Statement preparation and posting

If the claims were approved, the biller will then receive a report from the payer. In this step, a statement is done for the patient. If there are other charges that were not covered by the insurance provider, costs will be included in the statement.

Sometimes, the biller includes an EOB (Explanation Of Benefits) upon the issuance of the statement. This is helpful for the patient to know what benefits are included in their insurance plan, and can explain why certain costs were not included.

Step 10 – Collections and payments follow-up 

The last and final step is ensuring that the bills are completely paid. Statements and billing should be mailed out to patients in a timely manner. It should also follow that once the statement is paid, it should accurately reflect in the patient’s records.

There will be chances of statements going overdue, or patients not settling their bills in full. In this situation, billers should be able to contact the patients or follow them up consistently. 

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Processing medical billings is understandably tricky and time-consuming to keep up with. Knowing how to breeze through these processes is a sure-fire way to beat the hassles and stress of medical billing transactions.

This detailed guide to medical billing and coding for dummies is helpful for both medical practitioners and patients. However, if you’re a medical practitioner struggling to process your medical bills, or simply don’t have the time for it, allow us at MedCal to do the heavy lifting for you. Talk to us to know more.

References:

https://www.medicalbillingandcoding.org/billing-process/

https://www.dummies.com/article/body-mind-spirit/medical/billing-coding/medical-billing-coding-for-dummies-cheat-sheet-208289/

https://www.bryantstratton.edu/blog/2018/january/medical-billing-process

https://www.pettigrewmedical.com/the-key-steps-to-know-for-successful-medical-billing/

The post The Right Way To Process Medical Billing And Coding (For Dummies) appeared first on MedCal Inc.