All about Medical Billing in U.S.A

Download ABN Form 2011 for free

noreply@blogger.com (Vijay) — Sat, 11 Jun 2011 09:43:00 +0000

Hello everyone !!!

Sorry for the late post about the new ABN form. Well You guys were going to cms website to download the new ABN form which would be effect from Sep 01 2011. Well you can download the file from this website here itself from the links below. There is a pdf file with all the instruction and you can also print the ABN form which is in the Page 27 and Page 29 and start using it and you can also find the spanish version of ABN form also. I have placed the sample form screen shot for referrence and for more clarification please feel free to leave your comments and I will try my best to answer your queries.

Sample Screenshot of ABN form

Download ABN Form which has to be used from Sep 01,2011.

Download ABN form SPanish & English version with Instruction

Download ABN form English version PDF file

PPost Before “read more” And here is the rest of it

CMS released a new ABN form

noreply@blogger.com (Vijay) — Sun, 22 May 2011 14:35:00 +0000

CMS released a new ABN form

New ABN form was released by CMS recently on May 16th,2011 and its mandatory for everyone to use this form from Sep 01, 2011. You can also start using this form from now also so it would be very easy and handy than waiting till Sep 01, 2011.
You can download it from this website. The links are below for ABN form.

Download ABN Form English Version in PDF

Download ABN form Spanish & English version with Instruction

I would update the sample of new ABN form in my next post as I have to hurry up for some work sorry guys for just giving you the direct links to go through without explaining in detail what the new updates are.
Even I found an exceptional link that will help explain in detail the changes to come with 5010 and ICD-10. There are even videos and it's all free. It's at the governments website ( cms ) you can take look at the link too for more updates.

https://www.cms.gov/ICD10/02b_Latest_News.asp#TopOfPage

Latest News
PPost Before “read more” And here is the rest of it

ACCOUNTS RECEIVABLES - CALLING

noreply@blogger.com (Vijay) — Sat, 30 Apr 2011 07:36:00 +0000

ACCOUNTS RECEIVABLES - CALLING

The main thing in medical billing is AR calling. This help us to check why are payments have not been received.

Medical accounts receivable follow-up involves following up with entities such as Insurance carriers, Physicians, Hospitals and patients for information required to resolve the pending accounts at the earliest. Calling is a support media for A/R Analyst to close an outstanding account. Calling is done on accounts which are outstanding for more than 40 days and for which no correspondence has been obtained.
SCOPE:
Calls are made to the following entities by an AR representative:

 Insurance carriers
 Hospitals
 Physicians office
 Patients

I will explain you need details about what exactly its all about the above calls to be made and why?

COMMON PHONETICS

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 17:07:00 +0000

In this section I am going to cover the common phonetics used on the regular bases as most of them do not follow the actual phonetics used mentioned as days go people try to change to easier one. Here is a list below with simple examples and you can use it too.

A As in Alpha
B As in Bravo/ Boy
C As in California
D As in David
E As in Edward
F As in Frank
G As in Girl
H As in Henry
I As in Indiana
J As in Jack
K As in Kite
L As in Linda
M As in Mary
N As in Nancy
O As in Oscar
P As in Peter
Q As in Queen
R As in Robert
S As in Sam
T As in Tango
U As in Uniform
V As in Victor
W As in Whisky
X As in X ray
Y As in Yellow
Z (zee) As in Zebra or Zullu

Most of them are used by all of them instead the actual phonetics. If you want the actual correct phonetics would post in next post.

Thanks for reading, Leave your comments and suggestion.

ACCOUNTS RECEIVABLES - CALLING

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 17:01:00 +0000

ACCOUNTS RECEIVABLES - CALLING

Medical accounts receivable follow-up involves following up with entities such as Insurance carriers, Physicians, Hospitals and patients for information required to resolve the pending accounts at the earliest. Calling is a support media for A/R Analyst to close an outstanding account. Calling is done on accounts which are outstanding for more than 40 days and for which no correspondence has been obtained.

SCOPE:

Calls are made to the following entities by an AR representative:

 Insurance carriers
 Hospitals
 Physicians office
 Patients

PATIENTS

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 16:55:00 +0000

PATIENTS:

Calls are made to the patient to confirm on the insurance policy details, to obtain and confirm on the patient’s other insurance details or to inform the patient about their responsibility that is due from them to the doctor.
UNDER WHOSE NAME DO WE CALL CARRIERS & PATIENT’S?

Calls are made to patients and insurance companies, hospitals, physician’s office under the client’s name. Thus the carriers and patients would have no way of knowing that they are being called from an outside firm, but rather the clients’ in house collections department.
WHO RECEIVES THE PAYMENT COLLECTED BY THE AR REPRESENTATIVE?
The accounts receivables would be managed under the client’s name, therefore the payments would be made directly to the client account as specified.

AR Calling - PHYSICIAN’S OFFICE

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 16:54:00 +0000

PHYSICIAN’S OFFICE:

Calls are made to the physician’s office/PCP office to obtain and confirm on the referrals, to confirm on the patient’s coverage information incase a contact cannot be established with the patient.

Ar Calling - HOSPITALS

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 16:53:00 +0000

HOSPITALS:

Calls are made to the hospitals to check on the pre-authorization, pre-certification, to confirm on medical records and also to check on patient’s coverage information in case a contact cannot be established with the patient.

Ar Calling INSURANCE CARRIERS

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 16:53:00 +0000

INSURANCE CARRIERS:

Calls are made to insurance carriers for the following reasons :
1. Patient eligibility verification:
Calls are made to the insurance carrier to confirm on the eligibility of the insured, the type of insurance the subscriber has with the respective insurance and/or the benefits that are covered by the insurance.
2. Provider enrollment department :
Calls are made to the insurance carrier to confirm on the provider enrollment details. In order to check whether the provider is participating with the insurance and/or to enroll the provider with the insurance carrier.

3. Claim status:
Calls are made to insurance company to enquire about the status of a claim that has already been filed to them, but for which there has been no correspondence from the insurance company for over 40 days.

What are the tools used by an AR Analyst in Claim Analysis Process?

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 16:50:00 +0000

Today I am going to explain you about the various tools used by an AR Analyst for calims analysing.
AR analysts uses the following tools, reports and documents to identify and investigate issues that are affecting cash flow and preventing timely and accurate reimbursement of claims by payers. One or more, and sometimes all, of the following tools, source documents and resources are required for complete and effective AR analysis:

• Patient Account Ledger
• Explanation of Benefits (EOB)
• Regular Mail or Correspondences
• AR calling
• System Reports like
1. AR Reports
2. Custom Reports
3. Financial Reports
4. Electronic Transmission Reports

The extent to which the above mentioned tools and resources are used will depend on the account receivables situation in the accounts. The AR analyst measures the success of collection efforts by computing the current and past AR and collection’s in the specialty and account he/she is handling, comparing it against industry standards, wherever available. The analyst investigates the reasons for any rise in AR or any fall in collections using the tools and documents mentioned above. The objective is to minimize AR and maximize the collection rate.

links

noreply@blogger.com (Vijay) — Sat, 26 Mar 2011 15:13:00 +0000

Links Webpage

<% ' # THE FOLLOWING BLOCK IS USED TO RETRIEVE AND DISPLAY LINK INFORMATION. ' # PLACE THIS ENTIRE BLOCK IN THE AREA YOU WANT THE DATA TO BE DISPLAYED. ' # Dimensioning variables - DO NOT MODIFY! Dim UserKey Dim ThisPage Dim OpenInNewWindow Dim PostingString Dim PassedQuery Dim AllowSearch Dim ErrorString Dim ResultString Dim Category ' # // Finished dimensioning variables. ' # .com user key: UserKey = "4748" ' # YOU MAY MODIFY THE VARIABLES BELOW: ' # The following variable defines whether links are opened in a new window ' # (1 = Yes, 0 = No) OpenInNewWindow = 1 ' # The following variable determines whether the search function is enabled ' # for your links page (1 = Yes, 0 = No) AllowSearch = 1 ' # DO NOT MODIFY ANYTHING IN THIS BLOCK!! ' --------------------------------------------------------------------------------- ' # The following variable is sent to the server in order to ' # generate working links on your page: ThisPage = Request.ServerVariables("SCRIPT_NAME") ' # Generate the data to post to the .com server PostingString = "&UserKey=" & UserKey PostingString = PostingString & "&ScriptName=" & ThisPage PostingString = PostingString & "&OpenInNewWindow=" & OpenInNewWindow PostingString = PostingString & "&AllowSearch=" & AllowSearch ' # pass through any querystring data to to allow paging PassedQuery = Request.QueryString Category = Request.QueryString("cn") ' --------------------------------------------------------------------------------- Function GetLinksData(strQuery, strPost, ByRef strResponse, ByRef strError) Dim hObj Dim ComponentString Set hObj = Nothing On Error Resume Next Set hObj = CreateObject("WinHttp.WinHttpRequest.5.1") ComponentString = "" & vbCrLf
On Error Resume Next
If hObj Is Nothing Then
Set hObj = CreateObject("WinHttp.WinHttpRequest.5")
ComponentString = "" & vbCrLf
End If
On Error Resume Next
If hObj Is Nothing Then
If TryMSXML(strQuery, strPost, strResponse, strError) Then
' the MSXML function will return the data
GetLinksData = True
Else
' we don't need to supply error information, since the error string
' is passed ByRef, the MSXML function will supply the data
GetLinksData = False
End If
Else
hObj.Open "GET", "http://linktradeexchange.com/get_pages.php?" & strQuery & strPost, False
hObj.Send

If hObj.Status <> 200 Then
strError = "Error: Status=" & hObj.Status & " Text=" & hObj.ResponseText
GetLinksData = False
Else
strResponse = ComponentString & hObj.responseText
GetLinksData = True
End If
End If
End Function
Function TryMSXML(strQuery, strPost, ByRef strResponse, ByRef strError)
Dim hObj
Set hObj = Nothing
' let's see if the server supports the XMLHTTP component, various versions
On Error Resume Next
Set hObj = CreateObject("Msxml2.ServerXMLHTTP")
ComponentString = "" & vbCrLf
On Error Resume Next
If hObj Is Nothing Then
Set hObj = CreateObject("Msxml2.ServerXMLHTTP.4.0")
ComponentString = "" & vbCrLf
End If
On Error Resume Next
If hObj Is Nothing Then
Set hObj = CreateObject("Microsoft.XMLHTTP")
ComponentString = "" & vbCrLf
End If
On Error Resume Next
If hObj Is Nothing Then
strError = "No support for HTTP requests found."
TryMSXML = False
Else
' # Open connection to .com server, sending the UserKey information via POST
' # Also, pass through the querystring information (contains category, link information)
hObj.open "GET", "http://linktradeexchange.com/get_pages.php?" & strQuery & strPost, false
hObj.Send

If hObj.status <> 200 Then
' # error!
strError = "Error: Status=" & hObj.status & " Text='" & hObj.responseText & "'"
TryMSXML = False
Else
' # We should have received the links information from the server,
' # the following line will return the data by reference:
strResponse = ComponentString & hObj.responseText
TryMSXML = True
End If
Set hObj = Nothing
End If
End Function

If GetLinksData(PassedQuery, PostingString, ResultString, ErrorString) Then
Response.Write ResultString
Else
' here we are just dumping error info to the page. You can clean this up to
' fit your site
Response.Write ErrorString
End If

' # //FINSIHED .COM SCRIPT BLOCK
%>

Medicare Announces Charging for Enrollment

noreply@blogger.com (Vijay) — Fri, 25 Mar 2011 04:38:00 +0000

Medicare will start charging fees for some enrollment applications
Wow, I’m not sure why this surprised me so much but when I saw this email I was surprised. Medicare is going to start charging providers who submit enrollment applications? Well it’s not all providers, but still it is going to affect many. But the CMS (Centers for Medicare and Medicaid Services) announced that effective Friday, March 25, 2011 Medicare Administrative Contractors will begin collecting application fees for certain provider/supplier enrollment applications. This is for both paper and online, or PECOS, applications.

How much will this application fee be? That is the first question I had. But the answer is not clear. There is a published document at http://www.GPO.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-1686.pdf but it was a little difficult to wade thru all 110 pages. It appears that they are charging $500 for new enrollments for 2010 but since it wasn’t effective until March of 2011 I was left a little perplexed. Anyway, it looks like the fee for 2011 is $512 for new enrollments and $200 for revalidations and/or adding practice locations.

Also, the fee is not applicable to all providers. The fees do not apply to physicians, non-physician practitioners, physician organizations, and non-physician organizations. It is only applicable for institutional providers of medical or other items or services or suppliers. It is applicable for the CMS-855A, CMS-855B (not including physician and non-physician practitioner organizations), and CMS-855S applications.

Personally, I think this is going to cause some major confusion. As if it wasn’t hard enough for providers to just figure out what forms need to be submitted, now they need to determine if they need to pay. Also, some of the MAC’s (Medicare Administrative Contractors) are already difficult to deal with. (Just for the record, some are very pleasant and helpful.) Now they have another way that they can return apps stating that the fee was not included, even if no fee was needed. As we all know, Medicare being a government agency is full of red tape. If the provider makes a mistake they have to fix it, but if the MAC makes a mistake, the provider still has to fix it.

And I find it very ironic that Medicare is now requiring all providers to accept payments thru EFT (electronic funds transfer) but they are requiring payment for these apps by paper check. They haven’t developed a mechanism yet for receiving payment electronically. Of course they will have exceptions based on hardship but those will be determined on a case by case basis at the discretion of the MAC. I think consistency will be an issue there.

I’m usually a “glass is half full” person and as I read back thru this I feel I’m being quite negative. However, after doing thousands of Medicare applications over the past several years, I have seen many problems in the application process. To me, this addition of a fee is just going to complicate things even more. We’ll be watching to see how it plays out in future days.
courtesy - solutionsmb

The Payor of Last Resort

noreply@blogger.com (Vijay) — Mon, 21 Mar 2011 18:49:00 +0000

Remember one thing Medicaid is always the last payor.
If third party liability exists, then Medicaid is always the payor of last resort. This simply means that Medicaid always pays last where other insurance is present.

Whenever you receive a Medicaid denial advising you to bill the primary insurance, it is because Medicaid has on file that the recipient has other insurance. Recipients are required to keep Medicaid informed of any health insurance information. Providers are also responsible for notifying Medicaid of third party insurance they find out about as well as informing Medicaid of any third party payments they receive on behalf of the recipient.

State Medicaid agencies are required to reject claims wherever third party liability exists if they receive a claim without documentation of the primary insurance payment.

In instances that third party exists, if the Medicaid allowed amount is greater than the third party payment, Medicaid will pay the difference up to Medicaid's allowed amount. However, in instances that the third party payment is more than what Medicaid allows, Medicaid makes a "zero payment". This means that the provider must accept the primary insurance payment as payment in full and cannot balance bill the patient.

It is important to keep in mind that Medicaid is not an insurer. Medicaid is a program that makes medical payments on behalf of the recipient. If the provider or recipient fail to comply with any health insurance requirements that results in a denied payment, Medicaid can deny also due to noncompliance.

Third party liability is not just limited to Medicare and health insurance. It also refers to liability insurance due to motor vehicle accidents and work-related injuries or illness. For specific information on billing Medicaid claims, refer to your state Medicaid agency.

Reduce Your Medical Expenses with a Health Savings Account

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:41:00 +0000

Health Savings Accounts or HSAs are a new healthcare financing option introduced in 2004 that allows consumers to set up tax-deferred investment accounts tied to their health insurance policy and to use these tax-deferred funds to pay for incurred medical expenses. In essence, after setting up and funding an HSA in accordance with Federal and state regulations, you will be able to pay for many health-related expenses using pre-tax money. For most people, this is equivalent to receiving a 15% to 40% discount on qualified medical expenses! Consumers will realize even further savings by purchasing health insurance with a high deductible level -- a condition necessary to qualify for an HSA. In most cases, the benefits available under the HSA will offset the risk of that higher deductible level.

Let's look at how an HSA is normally established to better understand how this financial instrument works. An individual or family needs health insurance coverage, but must manage their overall expenses for healthcare. They choose a policy with a high deductible level (required for an HSA) in order to reduce their monthly premium. But, they are careful to select a plan that offers an attached HSA with the policy. Each tax year, this individual or family contributes funds into their HSA as follows (2006 rates): singles - $2700; families - $5450; and persons over 55 - an additional $700 per person. The actual contribution amount is claimed as a deduction against gross income on their tax return, reducing the amount of taxable income by an equal amount, even if they do not itemize deductions. The money in the HSA receives tax treatment similar to an IRA, and the investment growth of the money is not taxable while it remains within the account. At any time, money in the HSA can be withdrawn as needed to pay medical expenses without ever paying taxes or penalties. Finally, upon a person reaching the age of 65, HSA money can be withdrawn or spent for any purpose without penalty or taxes.

Another exciting advantage of an HSA is the wide array of medical expenses considered valid for the use of HSA pre-tax funds. Here is just a sampling of the types of services that can be paid for with HSA (pre-tax) money:

Dental - All expenses for regular exams, X-rays, cleanings, crowns, orthodontics, periodontics, dental supplies (toothpaste, floss) and prepaid dental plans.

Vision - All expenses for eye examinations, glasses, contact lenses, prescription sunglasses, and vision supplies (eyeglass cleaner, eye drops and contact lens solution).

Doctors - All expenses for office visits, labs, X-rays, medical supplies for asthma or diabetes, maternity, hospitalization, urgent care or emergency care.

Mental Healthcare - All expenses for psychiatrists, psychologists, therapists and counseling.

Alternative medicine - All expenses associated with naturopathic, chiropractic, acupuncture, homeopathy, ayurvedic medicine, and herbal medicine, all of which are not normally covered by health insurance.

For people seeking a way to assure good healthcare coverage for themselves or their families at a reasonable price, the HSA is a valuable tool in their arsenal. With the benefits offered through an HSA, they can choose an insurance policy with a high deductible, thereby dramatically reducing their monthly premium. When they take a portion of their monthly premium savings and fund their HSA, they will soon have access to discounted, pre-tax funds to pay for a wide variety of out-of-pocket medical expenses. And, if medical expenses remain low, the HSA savings will remain in the account for future years and for investment growth over time, much like a traditional IRA.

What to Do When Your Health Insurance Won't Cover Your Medical Care

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:39:00 +0000

It is becoming increasingly expensive to get a health insurance coverage nowadays. However, health insurance is a long term investment that would save you money in the long run.

If you have looked at the various health insurance plans, you would have noticed that there is no health insurance plan that will cover every kind of medical treatment you will need during your lifetime.

Regardless of how good your health insurance is, you may someday need to be treated for a health condition that is not covered by your health insurance policy. Elective treatments like cosmetic surgery and liposuction are typically not covered by health insurance plans but there are other health conditions and medical procedures that may not be covered.

If you ever need to undergo a treatment or procedure that your insurance policy does not cover but the treatment or procedure is not specifically mentioned in the "excluded treatments" section, inquire with your insurance company. Request a written explanation that states their reasons for not covering the treatment or procedure that you need to have. Show this letter to your doctor. Most of the time, a treatment or procedure simply needs to be re-stated and then presented to the insurance company, have it approved and get your treatment or procedure covered.

However, you could land in a situation where the treatment or procedure cannot be re-phrased, or the treatment has already been given to you and now the company denies you the coverage. The fact is, you do not have much options left. You might need to spend your own money for the treatment or procedure.

If your health insurance company denies your claim for coverage, you can make an appeal. Insurance companies have procedures for appealing a claim so you would need to follow the procedure of your insurance company. Insurance companies would generally reject an appeal based on technicality rather than use their resources to investigate the claim. Thus, if you decide to go with this route, make sure you follow all the steps. Check with your policy handbook as the proces to appeal would be in there. It is also good if you seek advice from your doctor before filing an appeal.

If, after going through all the process and following the steps for appealing a claim, you still lose, don't give up. The other options you can follow and which can save you from bearing the entire expense are:

1. Negotiate with your doctor for lower payment or if he can approve a payment plan.

2. Is your doctor a member of a medical discount program? Check with your doctor because many doctors do join such networks and groups.

3. If you have not started treatment or undergone a procedure yet, do a little research and find another doctor who can give you the same but at a lower cost.

4. Check if you are eligible for free treatment at a public hospital or clinic based on your income level, veteran status or some other socio-economic reason.

Be persistent and you will surely find a treatment or procedure, the price of which is affordable for you

California Medical Insurance Companies

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:36:00 +0000

California is one of the largest health insurance markets in the United States as many companies offer medical insurance plans in the state. In order to offer insurance in the state, a company must have a license from the state of California. This is a highly regulated process in order to ensure that insurance carriers have substantial assets and the necessary infrastructure to offer health insurance. General insurance companies like Aetna, New York Life, Prudential charge higher premiums. These general carriers do not have any specialized delivery mechanisms and usually third parties administer their plans. Specialized insurance giants like Blue Cross and Blue Shield are able to keep costs down with local delivery infrastructure and therefore offer lower premiums to the consumers. Health Maintenance Organizations (HMO) such as Kaiser and HealthNet maintain premiums even lower than the specialists and therefore, have developed a giant share of the market. HMO organizations manage to have such low premiums as they intervene in the health care delivery process as well. In some cases, for instance where carriers run their own delivery centers in California, as Kaiser does, it becomes quite possible to offer such inexpensive rates.

Medical insurance has multiple components and can be underwritten by specialized providers. Dental and vision insurance plans are some examples of this specialized underwriting. The terms of these plans vary widely as do their underwriting guidelines. Therefore, consumers have to be careful about the kind of plan they choose. There are also specialized carriers offering packages that specifically cover disability.

For those who cannot afford health coverage but are eligible for medical aid, the State of California provides a state government driven program. The state of California runs its own facilities to deliver medical benefits to medical recipients.

Electronic Medical Billing Software and Service - Top 4 Transparency Attributes

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:35:00 +0000

Medical billing industry has volumes of arcane terminology and payer- and time-dependent claim validity and pricing interpretation rules, facilitating massive payments of invalid or ineligible claims and denials of error-free claims. Process transparency provides its participants greater visibility of internal process activities. An increased level of access promotes teamwork, increases client satisfaction, and assists in process streamlining.

Billing process is the interaction between the participants (i.e., insurance company (payer), healthcare service provider (provider or doctor), patient, and billing service provider (biller)) designed to pay or deny a payment request (claim) submitted by the biller to the payer and to the patient on behalf of the provider. The amount and complexity of billing information make it very difficult for the doctor to maintain compliance and identify and resolve errors and underpayments.

Billing service transparency allows participants of the billing process to expedite error identification and resolution, resulting in reduced over- and under-payments and improved regulatory compliance.

Attributes of Billing Transparency

Billing transparency has four key attributes, including universality, continuity, ubiquity, and scalability.

• Universality: every participant in the billing process, including patient, provider, payer, and biller, has access to every aspect of the billing process.

• Continuity: process detail is available continuously on a 24 x 7 basis.

• Ubiquity: access to billing process is provided over secure standard Internet browser that requires no special hardware or software and is available everywhere.

• Scalability: both the big picture and minute detail are available for scrutiny universally and continuously. The big picture consists of total cash flow in a given time period, current submitted and failed claims, and billing quality metric. It must contain comprehensive summary of patient visits and unpaid balances. The minute detail pertains to individual claims making up the big picture, including complete history from the moment of creating the claim, testing its validity and eligibility, making corrections, performing submissions, reconciling payer messages and explanations of benefits (EOB) with original claims, until payment. Both perspectives must allow arbitrary aggregation of claims and drill in for detail to enable effective followup.

How to Build Transparency Into Your Billing Service?

A transparent billing service leverages technology to enable competent personnel to execute disciplined billing process. Therefore, to implement a transparent billing process, you must

[ ] Get access to adequate technology to support universality, continuity, ubiquity, and scalability.

[ ] Develop and thoroughly document claim processing procedures, including compliance and integration with practice workflow.

[ ] Train personnel in following the procedures and using the technology

[ ] Review personally and continuously billing quality, technology capabilities, adequacy of procedures, discipline, and training.

Note that Vericle-like technologies based on Straight Through Billing (STB) methodology implement billing transparency by design because billing transparency is an integral attribute of every component of STB process.

Q & A on Credentialing a Medical Provider - Why is this Necessary?

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:34:00 +0000

Q. What is credentialing?

A. It is a process by which insurance carriers and hospitals verify the credentials of the medical provider. This includes verification of licenses, verification of malpractice insurance, verification of college degrees and background checks to disclose any felonies or criminal activity.

Q. Why is credentialing important? Who is it important to?

A. It is important to the provider to maintain his credibility with the insurance carriers and to hopefully receive a contract to participate in an insurance companies various programs. This is critical to a medical provider due to the fact that most of us want to see a doctor in our network as it creates a savings for us with our medical expenses. Most out of network benefits require us, the patient, to meet a deductible before any payments to the provider of services are made.

Q. How does credentialing help the medical provider?

A. Once a medical provider is credentialed and accepted into an insurance plan, their information is then posted in the provider directory. If a patient is looking for a medical provider in their network, they usually search by zip code. If a medical provider is not listed in that directory, the medical provider has missed the opportunity to get a new patient. Therefore, credentialing in a sense is a marketing tool as well.

Q. How does a medical provider go about the process of credentialing?

A. Credentialing is an extremely time consuming process and requires an individuals' undivided attention. Current documents must be attached to a standard application which should be type written for legibility. Documents include licenses, diplomas, resumes, and declaration pages of the current malpractice. A cover letter should accompany the application and documents, introducing the provider to the carrier or hospital. Most providers use an outside service for this process.

Q. How long does it take to be credentialed?

A. Most carriers take from 90-180 days to complete their credentialing process. Once the provider is credentialed, the applications goes before a committee for final acceptance into an insurance plan.

Q. How will the provider know if they are accepted into a plan?

A. Most carriers inform the provider via letter along with a welcome packet of some type. Another method is to track your application which requires someone to contact the carrier every couple of weeks to check the status of the application.

All in all, credentialing is a very important part of the medical providers' business.

Submitting Medical Insurance Claims - Which Form Do I Use?

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:31:00 +0000

When it comes to submitting medical insurance claims to the insurance companies, it is important to file the claims on the appropriate forms. The most common medical insurance form is the HCFA 1500.

The HCFA 1500 form is a 8 ½"by 11" white paper printed with red ink. It contains many fields that must be completed. In an effort to standardize the medical industry, HIPAA (Health Insurance Portability and Accountability Act of 1996) mandated that all medical service providers use the HCFA 1500 form when submitting insurance claims.

It is crucial that the fields on the HCFA form are filled out accurately and completely. If any information is missing or incorrect it can cause the entire claim to be denied. In some cases they will return the incomplete or inaccurate claim with an explanation as to why it is not being paid. Other times, you just don't hear anything. Did they end up with your socks that never returned from the dryer?

There are some instances that a HCFA wouldn't be used. If the claim is for an on the job injury, or a workers' compensation claim, then a workers' compensation form would be used. These forms vary from state to state, but can usually be found on the state's workers' compensation website.

In many states forms can be downloaded and printed or purchased in quantity by private suppliers. Some medical billing software comes with the capability of printing the workers' compensation forms. The workers' compensation forms are white with black print and have fields similar to the HCFA 1500 form. As with the HCFA 1500, it is important that these fields are filled out accurately and completely.

Facilities such as hospitals, outpatient clinics, and ambulatory surgery centers use a UB92 form. It is the facility version of the HCFA 1500. UB92 forms are also white with red ink, but the fields are different.

When claims are submitted electronically, no forms are needed as the claims are not ever printed to paper. The claims are actually put into the correct format and sent on to the insurance companies in a file. The claims can either be sent via the internet, or thru the phone lines.

HCFA and UB92 forms can be purchased from a variety of suppliers and they vary greatly in price. The higher the quantity purchased, the lower the price per form. Shop around to find the best buy.

How To Appeal When Your Medical Insurance Doesn't Pay

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:29:00 +0000

Here is an intresting article which I wanted to share with all the readers which I found really intresting.
Have you ever received a bill from your doctor and stopped breathing? Have you wondered why you are receiving a bill when you have medical insurance? Have you asked the question, why am I paying this astronomical monthly payment?

MEDICAL BILL:

When you receive a medical bill from any provider; example, doctor, hospital, lab or x-ray is it paid correctly? Has any payment from your medical insurance been paid to your bill?

When a payment has not been paid or very little and you call and speak to a representative from you medical insurance company and the doctor's office, what is the next step?

If you're medical provider is going to appeal your bill or claim, great. Just make sure they follow through in a timely manner. Some appeals are time sensitive.

If you're medical provider says it is your responsibility to appeal your claim keep reading.

APPEALING YOUR MEDICAL BILL:

1. Write a letter and explain why you feel your claim was not paid correctly or was not paid.

2. Make sure you have your name, address, city, state, zip code and telephone number on your letter.

3. The name of the person insured on your insurance plan. (Guarantor)

4. The name of the person that was seen by a provider.

5. The date of service the medical care was obtained.

6. The place of service the medical care was obtained.

7. Attach a copy of your explanation of benefits (EOB) you received from your insurance company.

8. Attach any correspondence you received from your insurance company prior to receiving the final explanation of benefits.

9. Attach a copy of your medical insurance card.

10. Attach a copy of all your medical records pertaining to this date of service. Include x-rays, lab slips, anything that will present your case completely with one viewing.

SECRET:

Insurance Companies need your date of service and place of service. This is how they track all your medical care by each individual provider.

Example:

You were seen by your doctor that morning in her office. That afternoon you were admitted to a hospital. Now you have two different providers on the same day.

Try to make your presentation as professional as possible. The person that will be reviewing all your information will expect to see your entire case presentation in one sitting.

If the appeal board needs more information from you, they will probably send you a letter or phone you.

EXCEPT:

You will not win an appeal if your deductible or co pay was not met. Another denial is a non-covered service. With this denial your medical provider can help you make a decision before you go through the entire appeal process.

Sometimes this is not entirely true and an appeal would be perfect.

So I say go for it. Appeal your claim. Pour your emotions and passions out in your letter to the appeal board.

If you do not have a computer to type your letter hand write it. Just make your letter legible. Sometimes a hand written letter is more effective.

Supplemental Medical Insurance - What is Supplemental Health Insurance?

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:27:00 +0000

Group health insurance rates have been increasing year after year and employers have been forced to make some drastic changes in their employee benefit programs. Many employers have changed their health insurance to high deductible plans. Dental Insurance has been discontinued by some companies as well as vision care. Disability programs have been trimmed down as well as group life insurance. This has created gaps in coverage and employees have had to look for alternatives for coverage that has been omitted or decreased in their benefit package. The answer to this problem has come in the form of supplemental health insurance. Supplemental health insurance companies will enroll employees with these products and the premiums are paid through payroll deduction.

Supplemental health Insurance Products

1. Disability Insurance - Supplemental disability insurance is sold to employees to fill in gaps or replace lost benefits. Long term and short term disability insurance can be purchased with a variety of waiting periods and benefit periods.

2. Life Insurance - Supplemental life insurance includes a variety of permanent plans as well as term life insurance. There are non-medical life policies available for larger groups when a certain amount of employees participate in the plan.

3. Dental Insurance - This is one of the more popular supplemental health products because it usually the first discontinued by the employer.

4. Cancer Insurance - The cancer policy is a single need policy with relatively low premiums.

5. Accident Insurance - The accident policy covers accidental injury and death. There are accident disability riders on some accident policies.

6. Hospital Income - The hospital income policy pays a daily dollar rate to the insured while hospitalized. These policies can pay as low as $10 per day and as high as $200 for each day hospitalized.

The need for supplemental insurance is stronger than ever before. These policies can also be purchased on an individual basis with most companies.

Child Medical Insurance

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:26:00 +0000

We love our children. From the moment we realize they are making their way into this world, we begin making plans for them. We want the best of everything for them, from homes and communities to schools and activities. We strive to raise them in safe, healthy, nurturing environments in hopes that they will grow into and remain safe, healthy, nurturing adults throughout their lives.

Child medical insurance must be included in our plans for our children. Children are constantly growing and exploring. They are active little people who spend a lot of time running, tumbling, playing sports, and creating potentially dangerous little games of their own. Plus, classrooms full of children are perfect breeding grounds during the cold and flu season. If your daughter's best friend has a cold, you can safely bet that your daughter will have the sniffles within a few days, too. Inevitably our children will get sick, hurt, need medicine or x-rays once in a while or even more often!

The health and safety of our children is our most important goal. Unfortunately, sometimes we find ourselves in situations when our jobs don't offer medical insurance. It is easier to tell ourselves "not right now" when it comes to treating a medical problem, but it is not that easy to tell our children "not right now" when they are running a dangerously high fever and ask us to help them feel better.

If you do not have medical insurance covered by your place of employment, or you are covered by medical insurance you purchase yourself, you need to stop and think about the medical insurance of your child. If you are not covered, or can not afford medical insurance for yourself or your child, there are agencies out there that will help you. You can find affordable, and sometimes even free, child medical insurance that will cover dental, vision, and health costs for your child.

Group Medical Insurance - It is Different but Here are Some Tips to Figure It Out

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:24:00 +0000

Group Medical Insurance is a type of health insurance that is purchased by employers as a benefit to their employees. The group policy is a master policy that covers all of the employees and describes the benefits and features of the health insurance plan. This can be a very expensive portion of employers overhead. Health benefits help maintain employee stability and morale. The employer shopping for group insurance today must be wary of the market place. It has changed. There are a lot more insurance scams. It is better to stay with reputable companies.

The small business community has to be more creative with their group health package. There is a growing demand for small businesses to employ the services of a professional benefit counselor to develop alternatives when purchasing or revising their health plans.

The insurance companies are well aware of the problem and have been hard at work developing new versions of Group health insurance plans. The insurance companies are using every avenue available to keep their business clients. Group policies have many more deductible options than in years past. There is a strong move toward encouraging the employees to enroll in Health Savings Accounts. These accounts help the employee to off-set the higher deductible expense. There is also a trend with Group Health carriers to partner with supplemental health insurance companies. The supplemental health insurance companies can help fill the gaps that the group health plan no longer provides.

Things to consider

1. Tax advantages of HSA - The health savings account is becoming a favorite option for employers and employees.

2. Higher Deductibles - this is more than a trend now. The higher the deductible-the lower the premium.

3. Supplemental Insurance - using supplemental insurance companies to fill in the gaps at a lower cost to the employer and employee.

Health and Medical Insurance - Comparing Managed Care Health Plans

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:23:00 +0000

Health insurance plans have been forced to take action to contain costs of quality health care delivery as health care costs have skyrocketed. Health insurance premiums, deductibles and co-pays have steadily increased, and health insurance companies have implemented certain strategies for reducing health care costs. "Managed care" describes a group of strategies aimed at reducing the costs of health care for health insurance companies.

There are two basic types of managed care plans; health maintenance organizations, or HMOs, and preferred provider organizations, or PPOs. So which health plan is best? How do you choose what type of health insurance best suits the health care needs of you and your family?

Both HMOs and PPOs contain costs by contracting with health providers for reduced rate on health care services for its' members, often as much as 60%. One important difference between HMOs and PPOs is that PPOs often will cover the costs of care when the provider is out of their network, but usually at a reduced rate. On the other hand, most HMOs offer no coverage for health care services for out-of-network providers.

Both HMO and PPOs also control health care costs by use of a gateway, or primary care provider (PCP). Health insurance plan members are assigned (or select) a primary care practitioner (physician, physician assistant, or nurse practitioner). Usually a family practitioner or internal medicine doctor for adult members or a pediatrician or family care practitioner for children. The primary care provider is responsible for coordinating health delivery for plan members. Cares by specialist physicians require referral from the primary care provider. This cost containment strategy is intended to avoid duplication of services (for example, the cardiologist ordering tests that have already been done by the PCP, or a sprained ankle being referred to an orthopedic) and avoid unnecessary specialist referrals, tests and/or procedures.

HMO and PPO plans also contain costs by requiring prior approval, prior authorization, or pre-certification for many elective hospital admissions, surgeries, costly tests and imaging procedures, durable medical equipment and prescription drugs. When such services are required, the provider must submit a request to the health insurance plan review department, along with medical records that justify the service. The request is reviewed by the health insurance company to determine whether the services are justified as "medically necessary" according to the health plan policy and guidelines. Review is usually performed by licensed nurses, and, if the reviewer agrees that the service is necessary, approval is given and the service will be covered by the health insurance plan.

As health care costs continue to rise, many indemnity health insurance plans, or "fee for service" plans are being forced to adopt some managed care strategies in order to provide quality health care and keep health insurance premiums affordable. And as long as health care costs continue to rise, the distinctions among PPO, HMO, FFS and other health insurance plans will become blurred. Rest assured, however, that managed health care is here to stay.

Medical Insurance Rate - Why Does It Change and How is It Decided?

noreply@blogger.com (Vijay) — Thu, 17 Mar 2011 17:21:00 +0000

Are you shopping for health insurance? Are you looking for the best rates? Are you totally confused? There are so many people scrambling for health insurance and are trying their best to compare the rates. This is not easy at first because the health insurance companies have had to come up with creative alternatives in their insurance portfolios. Those creative alternatives can give the average person an insurance headache.

The rising costs of hospital and physician services are always passed on to the consumer. The consumer depends on their insurance company to pay for their medical expenses in exchange for a premium. The medical rates are based on several criteria.

Here are a few:

1. Gender - Male/Female rates differ.

2. Tobacco - Non-Tobacco - Tobacco users are higher

3. Household Status - Single, Parent-child, Parent-children, Husband-Wife, Husband-wife-child, Husband-wife-children

4. Deductible - $500 to $5000 (with some companies)

There are some things that you can do to affect the rate. The most cost savings method is to choose a high deductible plan. The higher the deductible calculates into a lower the rate. Low deductibles no longer justify the premiums paid. This trend toward high deductibles is called self-insuring. You are taking on the financial responsibility for the deductible amount.

The best way to offset and prepare for the out of pocket deductible is to start a health savings account. This is a tax deductible savings plan for medical expenses. It's the equivalent of a medical IRA. The tax deduction offsets some of the out of pocket expense you incur with the higher deductible. Contact your tax advisor or accountant about starting a health savings account.