Introduction to PhysicianProfessional Claims andBilling
APPOINTMENTPATIENT CALLS / WALKSTO THE DOCTORS OFFICETO FIX THEAPPOINTMENT
DATE OF SERVICEONCE THE APPOINTMENT ISFIXED, PATIENT COMES TOTHE DOCTOS OFFICE ANDFILLS THE DEMO FORMS (i.e.,his address with contact #,DOB, Gender, SS#, EmployerInformation, policy nameand number, effective dateetc.) and signs the Breach ofConfidentiality.
CHECK-UPDOCTOR CHECKS THEPREVIOUS MEDICALHISTORY OF THE PATIENTAND CHEKS THE PATIENTAND DOES THEPROCEDURE AS PER THECURRENT ILLNESS.
MEDICAL TRANSCRIPTIONDOCTORS GIVE THEDICTATION TO THE MEDICALTRANSCRIPTIONIST FORMEDICAL RECORD KEEPING.(AS IT IS MENDATORY IN USATO KEEP THE MEDICALRECORD OF THE PATIENTS ATLEASET FOR 5 YEARS).
MEDICAL CODINGAFTER THE MEDICALTRANSCRIPTION IS DONE, THEDOCUMENTS / REPORTS ARE SENTTO THE MEDICAL CODINGDIVISION TO GET THE REPORTSCODED AS CPT (CURRENTPROCEDURAL TERMINOLOGY) ANDICD (INTERNATIONALCLASSIFICATION OF DISEASE) WITHTHE HELP OF CODING BOOKS ANDMAINTAINING CODINGGUIDELINES.
MEDICAL BILLINGONCE THE CODING ISOVER THE CODEDREPORTS / SUPERBILLSCOME TO THE BILLINGDEPARTMENT, WHEREBELOW MENTIONEDSTEPS ARE FOLLOWED:
DEMO ENTRYDEMOGRAPHICS OF THE NEW PATIENTS AREENTERED INTO THE BILLING SOFTWARE ANDUPDATION OF THE OLD ACCOUNS ARE DONE.
CRITICAL FIELDS – DEMO ENTRYPATIENTS INFORMATION:1. NAME2. DATE OF BIRTH3. GENDER4. SOCIAL SECURITY NUMBER (SS#)5. ADDRESS (INCLUDING ZIP)6. CONTACT NUMBER7. RELATIONSHIP TO THE INSURED8. MARITAL STATUSINSURED’S INFORMATION:1. ID Number2. Name3. Address )including Zip code)4. Policy and Group Name5. Insured’s Plan or Program name6. Insured’s Date Of Birth
CLAIM GENERATION OR CHARGEENTRYONCE THE ACCOUNT OF THE PATIENT IS CREATED INTHE BILLING SOFTWARE, CHARGE CAN BE POSTED.
CRITICAL FIELDS – CHARGE ENTRYa. Is the Patient’s Condition Related to: Employment, Auto Accident,Other Accidentb. Name of Referring Physicianc. ID Number of Referring Physiciand. Diagnosis Codese. Prior Authorization Number (if applicable)f. Dates of Service & Date of Hospitalization (in case of Inpatient)g. Place and Type of Serviceh. CPTi. Modifiers (if applicable)j. Linked Diagnosis Codes to the Procedure Codesk. Days or Units (if applicable)
CLAIM SUBMISSIONThere are two ways to submit the claims to the insurance companies:1. Electronic Data Interchange (EDI) / Electronic Media Claims submission (EMC): EMC isan electronic claims processing system that enables a provider to submit his/her claimsto the carrier by using there 5 digits payer id # more efficiently than the paper claims2. Paper Submission on different forms (such as CMS 1500, CMS 1450 or UB 92, ADA992000)Time taken by Medicare to pay a clean claim: Medicare statute provides for claims payment floorsand ceilings. A floor is the minimum amount of time a claim must be held beforepayment. A ceiling is the maximum time allowed for processing a clean claim beforeMedicare owes interest to the Provider of Services.Physicians and suppliers who file Paper Claims will not be paid before the 26th day after the dateof receipt of their claims. Clean claims filed Electronically will be paid not sooner than13 days after receipt.
CLAIM ADJUDICATIONProcessing of paper claims starts in the mailroom where theenvelops are opened, attachments unstapled, and clippedto the claim. Claims are then scanned into the computer.Processing of electronic claims begins when a file oftransmitted claims is received from the clearinghouse. (Theclearinghouse edits the claims before sending to theinsurance companies) and is opened in the claimsprocessing computer.
STEPS (CLAIM ADJUDICATION) -1. The computer scans each claim for patient and policy identificationand compares them with the master policy file.Claims will be automatically rejected if the patient and subscribernames do not match exactly with the names on the master policylist. Use of nicknames or typographical errors on claims will causerejection and return, or delay in reimbursement to the providerbecause the claim cannot be matched with the names on themaster list.2. Procedure codes on the claim form are matched with the policy’smaster benefit list. In the case of managed care claim, both theprocedures and the dates of service are checked to ensure thatservices performed were authorized and performed within theauthorized dates of services.
CLAIM ADJUDICATION – Cont.Any service determined to be a non-covered benefit is marked as anuncovered procedure or non-covered procedure and rejected for payment.Services provided to a patient without proper authorization or that are notcovered by a current authorization are marked as an unauthorized service.Patients may be billed for uncovered for non-covered procedures, but notfor unauthorized services.3. Procedure codes are cross-matched with the diagnosis codes to ensurethe medical necessity of all services provided. Any service that isconsidered not “medically necessary” for the submitted diagnosis codemay be rejected.4. The claim is checked against common data file. The informationpresented 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 stepdetermines whether the patient is receiving concurrent care for the samecondition by more than one provider. This function further identifiesservices that are related to recent surgeries, hospitalizations, or liabilitycoverages.
CLAIM ADJUDICATION – Cont.5. A determination is made by “allowed charges”. If no irregularity orinconsistency is found on the claim, the allowed charge for each coveredprocedure is determined. (The allowed charges is the maximum amountthe insurance company will pay for each procedure or service, accordingto the patient’s policy. The exact amount allowed varies according thecontract 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. (Thedeductible is the total amount of covered out-of-pocket medical expensesa policyholder must incur each year before to insurance company isobligated to pay any benefits)7. The co-payment or co-insurance requirement is determined.
8. The Explanation of Benefits (EOB) is completed. The (EOB) form orreport is a statement telling the patient or provider how the insurancecompany determined its share of the reimbursement. The report includesthe 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 thepolicy.c). A list of all the allowed charges for each covered procedures.d). The amount of the patient deductible, if any, subtracted from the totalallowed charges.e). The patient’s financial responsibility for cost sharing (co-payment forthis claim.f).The total amount payable by the insurance company on this claim.CLAIM ADJUDICATION – Cont.
9. EOB and benefit check is mailed. If the claim form stated that directpayment should be made to the physician, the reimbursement check and acopy of the EOB will be mailed to the physician. This can be accomplishedin one of three ways:a). The patient signs the Authorization of Benefits Statement, Block 13 onthe 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 directpayment of all claims.If reimbursement is to be sent to the patient, the policyholder will receiveda copy of the EOB; explanation is sent to the provider by most carriers,without payment.CLAIM ADJUDICATION – Cont.
PAYMENTSPAYMENTS: Amount paid to the physicians against the services rendered by them tothe patient.THE SERVICES THAT ARE PROVIDED TO THE PATIENTS ARE SENT OUT TO THE INSURANCECOMPANIES 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 BILLINGCOMPANIES’ ADDRESSES. IN CASES WHEN THEY ARE RECEIVED AT THE PROVIDERS’ ADDRESSESTHEN THEY ARE IN TURN FORWARDED TO THE BILLING COMPANY TO THE PAYMENT IN THEIRSYSTEM. SUCH PAYMENTS COME IN THE FORM OF BATCHES AND MAY HAVE BANK’S DEPOSIT SLIPOR PAYMENT LISTING WITH THEM. PAYMENTS THAT ARE RECEIVED DIRECTLY AT THE BILLINGCOMPANIES’ ADDRESS DO NOT HAVE THE BANK’S DEPOSIT SLIP. PROVIDER CAN ALSO SIGN-UP FORERA (ELECTRONIC REMITTANCE ADVICE ) AND EFT (ELECTRONIC FUND TRANSFER )SOMETIMES, IN THE CASE OF NON-PARTICIPATING PROVIDER’S, PAYMENTS ARE RECEIVED BY THEINSURED PARTIES ADDRESS AND THEY FORWARD THE PAYMENT TO THE PHYSICIAN’S ADDRESS.
DENIALSClaim that do not get paid, come back as Denials from the Insurancecarriers. This can be due to posting errors, incorrect procedure / diagnosiscodes, lack of information (medical records) while filing the claims, ormissing / incomplete patient details.Denials are broken down into two categories: In-House and PatientResponsibility.In-House denials are the ones that require some type of correction fromour part and can be resubmitted. We do not bill patient.Patient Responsibilities are those denials that we can’t do anything to getthe claim paid by the insurance company. Al we can do is, transfer thecharge to the patient with the correct message code.
A/R MANAGEMENTThe following guidelines are intended to assist staff who are engaged inThird Party or self follow-up. The guidelines are consistent with theFair Debt Collection Practices Act. It is important for the billingservice, as a third party involved in the billing and collection of ourclient’s accounts, to confirm our guidelines to the Act to the assurethe protection of the billing service and it’s clients.CAUTIONARY GUIDELINESBefore 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 yourway down up to 45 days of balance outstanding.3. For Self-Pay patients, after one statement has gone out, F/U should be doneafter 30 Days from the date statement was mailed.4. Review account notes and transaction history. Make sure that the billingservice is not at fault.5. Plan what you want to say before making a call.
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 withan account or any confidential information – you do not know who will retrieve themessage. 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 collectionaction.” It is important to remember that any threatened collection action must be taken ifthere is no change in account circumstances. Not all clients will transfer account tocollection, 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 contactwith the debtor and direct all communications to the attorney.
A word about fraud and abuse…Fraud and Abuse GuidelinesFraud: “Intentional” deception ormisrepresentation that someone makes knowing itis false, that could result in an unauthorizedpayment.Abuse: “Actions that are inconsistent with acceptedsound medical, business or fiscal practices. Abusedirectly or indirectly results in unnecessary costs tothe [Medicare] program thru improper payment.”
Coding and billing as an identified potentialrisk area for fraud and abuseBilling for items or services not rendered or not provided asclaimed (fraud)Submitting claims for equipment, medical supplies and servicesthat are not reasonable and necessary (abuse)Double billing resulting in duplicate payment (abuse)Billing for non-covered services as covered (fraud)
Coding and billing as an identified potentialrisk area for fraud and abuseKnowing misuse of provider identification numbers, whichresults in improper billing (fraud)Unbundling (assigning multiple codes for a service that iscovered by a single comprehensive code) (fraud)Failure to properly use coding modifiers (fraud)Clustering (selection of the same level of E/M servicerepetitively) (abuse)Upcoding or coding at a higher level of service than actuallyprovided (fraud and abuse)
Tips to prevent fraud and abuserelated to coding:Never make changes to a diagnosis code or CPT code on a claimor edited invoice without evaluating the documentation firstUse the correct version of ICD-9-CM/CPT/HCPCS based on thedate of serviceICD-9-CM codes should be selected to the highest specificitybased on documentationSelect the CPT code which best describes the service performed.For services that do not have a specific CPT code to describe, usethe unlisted code from the appropriate categoryWhen using a CPT modifier, make sure the combination with theCPT code is appropriate
Tips to prevent fraud and abuserelated to coding:When using a CPT modifier, make sure the combination with theCPT code is appropriateUse a comprehensive CPT code if available in reporting aprocedure or surgery. Never use multiple codes to describe aservice when a single comprehensive code is availableFamiliarize yourself and stay up to date on payer coveragepolicies that you frequently codeCommunication: keep providers well informed regardingdocumentation and coding requirements