Basic Requirements to Setup Medical Billing process

1. MEDICAL BILLINGMEDICAL BILLING
PROCESSPROCESS
REQUIREMENT TO SET UPREQUIREMENT TO SET UP
NEW PROJECTNEW PROJECT
By Kuldeep Singh RawatBy Kuldeep Singh Rawat
Freelance Consultant-Freelance Consultant-
US HealthcareRCM ProcessUS HealthcareRCM Process

2. IndexIndex
 OverviewOverview
 Basic Requirement of ProjectBasic Requirement of Project
 Departments and their RolesDepartments and their Roles
 Data Migration process need to be setData Migration process need to be set
upup
 Team ManagementTeam Management

3. OverviewOverview
The medical Billing Industry is a subsidiary of HealthThe medical Billing Industry is a subsidiary of Health
Care Industry.Care Industry.
Medical billing is the financial data management of aMedical billing is the financial data management of a
physician or a group of physicians’ practices. Medicalphysician or a group of physicians’ practices. Medical
Billing is the practice of submitting claims to InsuranceBilling is the practice of submitting claims to Insurance
companies or the United States government, in order tocompanies or the United States government, in order to
receive payment for services provided to a patient by areceive payment for services provided to a patient by a
doctor.doctor.
This means maintaining physicians’ all the nonThis means maintaining physicians’ all the non
medical records and keeping track of and collecting allmedical records and keeping track of and collecting all
the money due to him.the money due to him.

4. Basic Requirement of ProjectBasic Requirement of Project
 Intelligent Practice Management SoftwareIntelligent Practice Management Software
 Effective Data Migration ProcessEffective Data Migration Process
 Active US and India DepartmentActive US and India Department
 Effective System should followEffective System should follow
 Human ResourceHuman Resource

5. Basic Requirement of ProjectBasic Requirement of Project continuescontinues
Intelligent Practice Management SoftwareIntelligent Practice Management Software
Any Practice Management Software is the center point of allAny Practice Management Software is the center point of all
the activities happen in the project because it is the base of the project.the activities happen in the project because it is the base of the project.
So, one should keep in mind the following while purchasing software forSo, one should keep in mind the following while purchasing software for
their use.their use.
 Software should have all the important packagesSoftware should have all the important packages
 Software should have user friendly. For Example. Some software looksSoftware should have user friendly. For Example. Some software looks
like the Hcfa 1500. Such kind of software are difficult to handle and thislike the Hcfa 1500. Such kind of software are difficult to handle and this
increase the error rates.increase the error rates.
 Software should have facility of clubbing of claims under oneSoftware should have facility of clubbing of claims under one
nomenclature so that in future if we want to see the claim documents fornomenclature so that in future if we want to see the claim documents for
AR purpose we can easily keep track of it.AR purpose we can easily keep track of it.

6. Basic Requirement of ProjectBasic Requirement of Project continuescontinues
 If software has document scanned and linked with claimIf software has document scanned and linked with claim
facility. Then it is wonderful.facility. Then it is wonderful.
 Lots of software in market have claim processing packagesLots of software in market have claim processing packages
but they lack in AR Management package. AR follow upbut they lack in AR Management package. AR follow up
package contains facility to view claim through its aging. Itpackage contains facility to view claim through its aging. It
should also have facility of maintain all the notes entered byshould also have facility of maintain all the notes entered by
AR Personal.AR Personal.
 Software should have facility to generate customized reportsSoftware should have facility to generate customized reports
in excel sheet also.in excel sheet also.

7. Basic Requirement of ProjectBasic Requirement of Project continuescontinues
 Effective Data Migration ProcessEffective Data Migration Process
Data is the most sensitive part in such kind of projects and it is theData is the most sensitive part in such kind of projects and it is the
responsibility of the billing company to take care of it once they receive. Soresponsibility of the billing company to take care of it once they receive. So
process needs to be set up as per HIPAA compliance so that every singleprocess needs to be set up as per HIPAA compliance so that every single
data can be tracked easily.data can be tracked easily.
 Active US and India DepartmentActive US and India Department
UUS and India will have their different departments which will play role toS and India will have their different departments which will play role to
make the project streamlined and successful.make the project streamlined and successful.

8. Basic Requirement of ProjectBasic Requirement of Project continuescontinues
 Effective System should followEffective System should follow
A kind of System needs to be setup where authorities have been delegatedA kind of System needs to be setup where authorities have been delegated
to every department and proper check is over every activity. It is importantto every department and proper check is over every activity. It is important
to take prompt action over any activity which is not in favor of project. But into take prompt action over any activity which is not in favor of project. But in
the mean time, working culture needs to be friendly where every one canthe mean time, working culture needs to be friendly where every one can
enjoy work.enjoy work.
 Human ResourceHuman Resource
Human resource is the back bone of any service industry. Especially whenHuman resource is the back bone of any service industry. Especially when
new process need to be setup it is important to have good peoplenew process need to be setup it is important to have good people
surrounding you so that proper procedures can be setup easily.surrounding you so that proper procedures can be setup easily.

9. Departments & their rolesDepartments & their roles
FLOW CHARTFLOW CHART
Document
Manageme
nt Dept.
Claim
Processing
Dept
AR Follow up
Dept
Cash Posting &
Denial Dept
Eligibility Dept
Pre Auth Dept
EDI Dept.
Paper Claim
and Patient
Statement
Co-ordination
and Reporting
Dept.
Practice
Manageme
nt Software

10. Departments & their rolesDepartments & their roles ContinuesContinues
Both India and US office has to Play their role efficiently to makeBoth India and US office has to Play their role efficiently to make
the process streamlined. It is important to have to divide theirthe process streamlined. It is important to have to divide their
roles. Ideal situation is US handles the administrative part androles. Ideal situation is US handles the administrative part and
India handles the Operation Part.India handles the Operation Part.
Following are the Administrative RolesFollowing are the Administrative Roles
 Software ManagementSoftware Management
 Data ManagementData Management
 Paper Claims and Patient Statement ManagementPaper Claims and Patient Statement Management
 EDI Management.EDI Management.
 Direct Client Interaction. (This role can be handled by India )Direct Client Interaction. (This role can be handled by India )

11. Departments & their rolesDepartments & their roles ContinuesContinues
Following are the Operation RolesFollowing are the Operation Roles
 Patient RegistrationPatient Registration
 Charge PostingCharge Posting
 Cash Posting & Denial Handling.Cash Posting & Denial Handling.
 Eligibility VerificationEligibility Verification
 Pre AuthorizationPre Authorization
 AR Follow-upAR Follow-up
Above role is ideal if Organization is planning to start a bigAbove role is ideal if Organization is planning to start a big
project. In this situation all controls should be in US side. Theproject. In this situation all controls should be in US side. The
major reason behind this has come in picture that India has verymajor reason behind this has come in picture that India has very
high iteration rate and these role require less resource sohigh iteration rate and these role require less resource so
administrative part should not be affected due to this. Secondadministrative part should not be affected due to this. Second
major reason is to keep tab on quality issue from their end.major reason is to keep tab on quality issue from their end.

12. Data Migration is the most crucial part of Project . There are twoData Migration is the most crucial part of Project . There are two
type of data where Migration should be taken care in a propertype of data where Migration should be taken care in a proper
way.way.
 Old DataOld Data
 Fresh DataFresh Data
Every Provider normally concerned about the old data, which isEvery Provider normally concerned about the old data, which is
not yet paid, while changing the Billing Company. So propernot yet paid, while changing the Billing Company. So proper
guideline is to be prepared while working on this data.guideline is to be prepared while working on this data.
Data Migration process need to be set upData Migration process need to be set up

13. Fresh Data should come in a proper way and every data weFresh Data should come in a proper way and every data we
receive should be acknowledged. For this we have to used thereceive should be acknowledged. For this we have to used the
following toolsfollowing tools
 Batch Cover Sheet – having complete information regarding theBatch Cover Sheet – having complete information regarding the
bunch of pages we have received from Client.bunch of pages we have received from Client.
 Intimation reportIntimation report
Data can be transmitted in a following way.Data can be transmitted in a following way.
 Via faxVia fax
 Ftp SiteFtp Site
 Courier.Courier.
Data Migration processData Migration process continuecontinue

14. Data Migration processData Migration process continuecontinue
Way of transmitting a data is also a bigWay of transmitting a data is also a big
question. It depends on provider because as per myquestion. It depends on provider because as per my
experience all the Doctors are not techno-savy. And if allexperience all the Doctors are not techno-savy. And if all
doctors have their own style of transmitting data, it is notdoctors have their own style of transmitting data, it is not
so easy to take care of it in a proper way. Normallyso easy to take care of it in a proper way. Normally
doctors or their staff uses fax to transmit data. But thisdoctors or their staff uses fax to transmit data. But this
cause problem because fax sometimes create problemcause problem because fax sometimes create problem
and half printed pages or irregular pages comes out inand half printed pages or irregular pages comes out in
the receiver end. Best option is either Ftp site or courier.the receiver end. Best option is either Ftp site or courier.
But in the Operation team should get data in a betterBut in the Operation team should get data in a better
way so that errors can be minimized.way so that errors can be minimized.

15. Team ManagementTeam Management
 India Team hierarchyIndia Team hierarchy
MANAGER
Team Leader
(AR Team)
Team Leader
(Billing Team)
Quality
Team/Trai
ning/ MIS
Reporting
Team
Billing
Team
AR
Team
Coder
Upper Mgmt

16. Team ManagementTeam Management continuecontinue
Initially it should be start with 6 People
Manager 1
Billing Personal 2
AR Personal 2
Coding Personal 1