Medical Billing 1


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Medical Billing 1

  2. 2. U S HEALTHCARE Medical Billing Claims Adjudication Medical Billing is the practice of submitting claims to Insurance companies or the United States government, specifically Medicare in order to receive payment for services provided to a patient by a doctor The insurance review department reviews the claim and after the edit checks, the claim is adjudicated and processed for payment. The check and the Explanation of Benefits are sent to the provider
  3. 3. Difference Between Indian & U S Healthcare Industry <ul><li>Indian Healthcare </li></ul><ul><li>All citizens do not have medical insurance to cover their healthcare needs </li></ul><ul><li>Patients have to pay upfront the total cost before the services are rendered by the Doctor </li></ul><ul><li>U S Healthcare </li></ul><ul><li>All citizens have medical insurance to cover their healthcare needs. </li></ul><ul><li>Patients do not have to pay upfront the total cost for the services to be rendered by the Doctor. </li></ul>
  4. 4. Billing Process
  5. 5. Billing Process                                                 
  6. 6. Doctor’s Office <ul><li>A patient visits the Doctor and gives his/her insurance card. </li></ul><ul><li>Patient fills the patient registration form at the front desk </li></ul><ul><li>Patient then explains his/her problem to the Doctor </li></ul><ul><li>The doctor then diagnoses the ailment and draws a chart explaining the treatment that needs to be rendered. </li></ul><ul><li>Eg: If the patients complains of frequent headache, a sequence chart would be drawn by the provider to explain the treatment pattern </li></ul>
  7. 7. Medical Insurance Card
  8. 9. Scanning <ul><li>Demographics, superbills/ charge sheets, insurance verification and a copy pf the insurance card and any other information pertaining to the patient, is either sent to the billing office or to our office </li></ul><ul><li>The billing office scans the source documents and saves the image files to an FTP site or onto their server. </li></ul><ul><li>Our scanning department retrieves the files. The images are split and arranged according to patient names </li></ul><ul><li>The files are sent to the appropriate departments with the control log for the number of files and pages received. </li></ul><ul><li>Illegible/missing documents are identified and a mail is sent to the Billing office for rescanning </li></ul>
  9. 10. Patient Super Bill /Encounter Form
  10. 11. Coding <ul><li>The coding team assigns the Numerical codes for CPT (Current Procedural Terminology) and the Diagnosis Code based on the description given by the provider </li></ul>
  11. 12. Patient Demographics <ul><li>In this department, the patients personal information is entered from the demographic sheets. </li></ul>
  12. 13. Charge Entry <ul><li>In this department, the relationship of the Diagnosis code and CPT is checked. </li></ul><ul><li>A charge is then created according to the billing rules pertaining to specific carriers and location. </li></ul>
  13. 14. Charge Entry Screen
  14. 15. Claims Transmission <ul><li>Claims are filed and information sent to the Transmission department. </li></ul><ul><li>The transmission department prepares a list of claims that go out on paper and through electronic media. </li></ul><ul><li>Once claims are transmitted electronically, confirmation reports are obtained and filed after verification </li></ul><ul><li>Paper claims are printed and attachments done, put into envelopes and sent to the US for postage and mailing. </li></ul><ul><li>Transmission rejections are analyzed and appropriate corrective action is taken. </li></ul>
  15. 16. Payment Posting <ul><li>The cash team receives the cash files (Check copy & EOB) and applies the payments in the billing software against the appropriate patient account. </li></ul><ul><li>During payment posting, overpayment are immediately identified and necessary refund requests are generated to obtaining approvals </li></ul><ul><li>Under payments/Denials are also informed to the Analysts. </li></ul>
  16. 17. Payment Posting Screen
  17. 18. Analysis <ul><li>AR Analysts are key to any group. </li></ul><ul><li>The claims are researched for completeness and accuracy and work orders are set up for the call center to make calls </li></ul><ul><li>AR Analysts are responsible for cash collections and resolving all problems to enable the account to have a clean AR </li></ul><ul><li>They also research the claim denied by the carriers, rejections received from the clearing house and low payments by the carriers. </li></ul><ul><li>The analyst reviews for global patterns and bulk problems are solved at one instance </li></ul>
  18. 19. AR Follow-up <ul><li>This is the hub of activity around which Medical Billing operates. </li></ul><ul><li>The caller will call up the insurance and verify if the claim is with the carrier and its current status. </li></ul><ul><li>The caller checks whether the claim is being processed for payment or denial </li></ul><ul><li>Based on the inputs from the caller, the analyst goes to work and gets the required pre-requisites needed. </li></ul><ul><li>Incase of payment, the analyst would compile a list of payments details or if denied then corrective action is initiated </li></ul><ul><li>The calling team receives work orders from the analysts and initiates calls to the insurance companies to establish reasons for non-payment of the claims. </li></ul><ul><li>All reasons are passed on to the analyst for resolution. </li></ul>
  19. 20. Month End Reports <ul><li>At the end of the month, Doctor Financials, aged summary reports so that we asses the momentum that has been achieved this month, and if not see where there is a pattern of non payment. </li></ul><ul><li>In this way, any bulk pending issues are tackled. </li></ul><ul><li>Any claim beyond the 60 day pending is acted upon, if it is pending for clarification then that needs to be informed to the respective account manager at the center so that remedial steps could be initiated. </li></ul>