Medical billing
Medical billing is a payment practice within the
The medical billing process requires accuracy, knowledge of medical coding guidelines, and familiarity with insurance policies to ensure timely and accurate
and others. Certification schools are intended to provide a theoretical grounding for students entering the medical billing field. Some community colleges in the United States offer certificates, or even associate degrees, in the field. Those seeking advancement may be cross-trained in medical coding or transcription or auditing, and may earn a bachelor's or graduate degree in medical information science and technology.It is not required to have a certification to learn billing, though it may help with employment prospects, and billing practices vary from state to state.
History
For several decades, medical billing was done almost entirely on paper. However, with the advent of medical practice management software, also known as health information systems, it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their own web-interfaces, which negates the cost of individually licensed software packages. Due to the rapidly changing requirements by U.S. health insurance companies, several aspects of medical billing and medical office management have created the necessity for specialized training. Medical office personnel may obtain certification through various institutions who may provide a variety of specialized education and in some cases award a certification credential to reflect professional status.
Billing process
The medical billing process is a process that involves a third party payer, which can be an insurance company or the patient. Medical
After the doctor sees the patient, the
The insurance company (payer) processes the claims, usually by medical claims examiners or medical
In case of the denial of the claim, the provider reconciles the claim with the original one, makes necessary rectifications and resubmits the claim. This exchange of claims and denials may be repeated multiple times until a claim is paid in full, or the provider relents and accepts an incomplete reimbursement.
There is a difference between a "denied" and a "rejected" claim, although the terms are commonly interchanged. A denied claim refers to a claim that has been processed and the insurer has found it to be not payable. A denied claim can usually be corrected and/or appealed for reconsideration. Insurers have to tell the insured why they've denied the claim and how the insured can dispute their decisions.[2] A rejected claim refers to a claim that has not been processed by the insurer due to a fatal error in the information provided. Common causes for a claim to reject include when personal information is inaccurate (i.e.: name and identification number do not match) or errors in the information provided (i.e.: truncated procedure code, invalid diagnosis codes, etc.) A rejected claim has not been processed, so it cannot be appealed. Instead, rejected claims need to be researched, corrected and resubmitted.
Electronic billing
A practice that has interactions with the patient must now, under HIPAA law 1996, send most billing claims for services via electronic means. Prior to actually performing service and billing a patient, the care provider may use software to check the eligibility of the patient for the intended services with the patient's insurance company. This process uses the same standards and technologies as an electronic claims transmission with small changes to the transmission format, this format is known specifically as X12-270 Health Care Eligibility & Benefit Inquiry transaction.[3] A response to an eligibility request is returned by the payer through a direct electronic connection, or more commonly their website. This is called an X12-271 "Health Care Eligibility & Benefit Response" transaction. Most practice management/EM software will automate this transmission, hiding the process from the user.[4]
This first transaction for a claim for services is known technically as X12-837 or ANSI-837. This contains a large amount of data regarding the provider interaction, as well as reference information about the practice and the patient. Following that submission, the payer will respond with an X12-997, simply acknowledging that the claim's submission was received and that it was accepted for further processing. When the claim(s) are actually adjudicated by the payer, the payer will ultimately respond with a X12-835 transaction, which shows the line-items of the claim that will be paid or denied; if paid, the amount; and if denied, the reason.
Payment
In order to be clear on the payment of a medical billing claim, the health care provider or medical biller must have complete knowledge of different insurance plans that insurance companies are offering, and the laws and regulations that preside over them. Large insurance companies can have up to 15 different plans contracted with one provider. When providers agree to accept an insurance company's plan, the contractual agreement includes many details, including fee schedules which dictate what the insurance company will pay the provider for covered procedures, and other rules such as timely filing guidelines.
Providers typically charge more for services than what has been negotiated by the physician and the insurance company, so the expected payment from the insurance company for services is reduced. The amount that is paid by the insurance is known as an "allowed amount".
The insurance payment is further reduced if the patient has a
A
Steps have been taken in recent years to make the billing process clearer for patients. The Healthcare Financial Management Association (HFMA) unveiled a "Patient-Friendly Billing" project to help healthcare providers create more informative and simpler bills for patients.[6] Additionally, as the Consumer-Driven Health movement gains momentum, payers and providers are exploring new ways to integrate patients into the billing process in a clearer, more straightforward manner.
Medical billing services
Some providers outsource their medical billing to a third parties, known as medical billing companies, which provide medical billing services. One goal of these entities is to reduce the amount of paperwork for medical staff and to increase efficiency, providing the practice with the ability to grow. The billing services which can be outsourced include regular invoicing, insurance verification, collections assistance, referral coordination, and reimbursement tracking.[7]
Practices have achieved cost savings through
See also
- Electronic medical record
- Healthcare Common Procedure Coding System
- International Classification of Diseases(ICD codes)
- Medically Unlikely Edit
- National Uniform Billing Committee
References
- ^ "Medical Billing Certification - Certified Professional Biller - CPB Certification". www.aapc.com. Retrieved 15 April 2019.
- ^ "How to appeal an insurance company decision". HealthCare.gov. Retrieved 2015-09-09.
- ^ X12 270 CM Glossary
- ^ "Medicare Coordination of Benefits (COB) System Interface Specifications 270/271 Health Care Eligibility Benefit Inquiry and Response HIPAA Guidelines for Electronic Transactions" (PDF). the U.S. Centers for Medicare & Medicaid Services. Retrieved November 4, 2020.
- ^ "What is an allowed amount?".
- ^ "Patient Friendly Billing Project". www.hfma.org. Retrieved 2015-09-07.
- ^ Tom Lowery (2013). "8 Ways Outsourcing Can Help Hospitals and Patients". HuffPost.
- ^ Reese, Chrissy (30 May 2014). "Realizing Affordable Healthcare: The Advent of Medical Billing". Fiscal Today. Retrieved 11 June 2014.
External links
- Medical Records and Health Information Technicians Career information at the U.S. Bureau of Labor Statistics