What is HIPAA?

HIPAA- is the Health Insurance Portability and Accountability Act of 1996
This law covers the privacy and security of medical records and protected health information. When we take patients information it is not to be shared with anyone unless it is work related. If a patient calls requesting information about their visit, ask them to fax something in writing authorizing release. If you give out patient information over the phone to the wrong person, you can be sued so its better to take every precaution necessary.

Sending Your Claim to the Insurance Company

If you are billing for a physician charge, you will bill your claims on a HCFA 1500 aka CMS 1500 form. You can see a sample here HCFA 1500 form

If you are doing facility or hospital billing only then you would use a UB92. You can see a sample UB92 here Sample UB92

To keep updated with constant changes of this form go to www.cms.gov

Insurance Company Payments

What is Payment Posting?

Payment posting is simply posting payments from the insurance company into the system. The insurance company sends a check along with an EOB. On the EOB the insurance company will tell you the allowed amount and the amount they paid. You would then bill the patient any copays, coinsurance or deductibles.

What is an EOB?

EOB means Explanation of Benefits. Insurance companies send information to both the patient and provider on exactly what they paid and allowed. Allowed amount means the maximum amount the insurance company would consider for payment. Any difference above the allowed amount is written off if the provider participates with the insurance company.

Example. The charged amount for the doctors’ visit was $100. The insurance company allowed $70($30 gets written off write away if the doctor participates) out of the $70(they allowed) they pay $50 and states patient has a$20 copay. The $50 they paid plus the $20 copay equals the allowed amount of $70.

If the doctor doesn’t participates with the insurance then the patient is liable for any balance left over after the insurance company pays. In this example, the patient would have to pay the $20 copay and the $30 since the doctor doesnt participate. The patient would be liable for $50 since the insurance company only paid $50. This is because the doctor doesn't participates.

ICD-9 and CPT Code

What is an ICD-9 code?(International Classification Of Disease)

Icd-9 is a diagnosis. The diagnosis is the reason a patient is being seen. For example: a patient comes to see the doctor for a headache. The diagnosis would be headache. A number is assigned to this by a coder. They choose the appropriated diagnosis code from the ICD-9 book and code it on the encounter form.

What is a CPT code?(Current Procedural Terminology)

Cpt code is the procedure that is being done. Ex. A new patient comes in to see the doctor for the headache, the doctor examined the patient. The cpt code would be a new office visit. The coder would then choose the appropriate cpt code from the CPT book and code it on the encounter form. Examples 99201-99205 are new office visit codes in the cpt book. Depending on how long the patient was seen determines the level and should be done by a certified coder or someone who has experience.

What is an encounter form?

You may have seen it before. This is the form the doctor attaches to your chart to give to the lady at front desk. This form has your demographic information along with insurance information. The office usually picks frequent icd-9 and cpt codes that they use often and preset it on the form. Most of the time the doctor will check off what diagnosis (icd-9) and procedure (cpt) they used and give to the person that will do the charge entry.

What is charge entry?

Charge entry is just entering the cpt codes and icd-9. The registration(the patients information, name, date of birth, social security number, address, insurance, etc) is usually already done by someone else who just does registration. When you are doing charge entry you enter information that is on the encounter form. Along with the patient demographics, you need to enter the date of service, the cpt code, the icd-9 and the charge amount if needed. Sometimes you need to put in the authorization number or referral information.

Other information that is needed to get the claim paid is normally preset to come out on all claims from the initial set up such as the provider tax id and address.

Medical Billing

When a patient is seen at the doctor or hospital, charges are sent out to the insurance company for their visit. We send those charges provided by the physician or hospital to the insurance company. The insurance company then determines if the claim will be paid and if the patient has a copay or coinsurance. Once they have process the claim, they send the provider a check along with an EOB(explanation of benefits) for the patient. If the patient has no insurance, we just simply bill the patient directly for the bill.