What Do You Do If the Insurance Companys Pays the Patient?

If the insurance companies pays the patient, then you can send your bill to the patient. It is best to get the date it was paid to the patient and when it was cashed because most patients will say they never received it but seems to remember when you give them all of the details.

If the provider participates with the insurance company, make sure that you check accept assignment on the HCFA form to avoid having future checks sent to the patient. If the provider doesn't participates, you can bill the patient directly up front in the future and have them submit their own claims in the future.

Acronyms for Medical Abbreviations

You can find most of the medical billing abbreviations at Global RPH

Some Common Diagnosis Codes for Family Physicians

Family Practice Management list most updated ICD-9 codes for family physicians.

ICD-9 updates and changes

Medical Billing Contracts

If you are going to try and create your own medical billing company, you should have a medical billing contract. You can either have a basic contract, or have an attorney draft up a contract.

In the contract there are some things to consider

Name of the billing company and the name of client.

Effective date of contract and expiration date if any.

Where will the insurance payments go to? I recommend having the payments go to the physician's office to avoid any legal matters. There should be a contract stating the provider will send copies of EOB's of all payments.

Providing monthly reports or meeting once a month or quarterly.

How will payments be made? You can either charge by percentage. Some of the average ranges are 8 to 15% or an average of $4 to $10 per claim. Things to consider are the patient volume, average income and if the client is established or not.

Who will do the coding? You will want to interview the company that you will be outsourcing with to make sure they are not doing anything illegal first. You do not want to do billing for a company that is in violation.
Once you have interviewed with them, you can either agree to have coding stay with them or choose to outsource coding as well for an additional fee.

Things that the client is responsible for:
provide true and accurate data(the client will be responsible for any submission of false date that can be prosecuted by law)
verify insurance
client will be responsible for his/her own credentialing
client will not offer kickbacks or professional courtesy to client(this means the client can not wave copay or give free services to preferred patients, THIS IS AGAINST THE LAW)

Note that claims and patient information belongs to the property of the client and the billing company is only using it while contracted with the client.

Billing company is responsible for
following up on unpaid claims
patient billing
paper and electronic submission of claims

Where to Apply For A NPI Number?

If you need a NPI number, the National Provider Identifier, number here is the information that you need to apply apply for NPI number

Medical Billing Forums

Billing-Coding
Medical Billing and Coding
Medical Association Of Billers
AAPC

Can I Wave Co-pays at the Doctors

You shouldn't wave copays at the doctors. This is considered a professional courtesy. If you tell a patient they don't have to pay a copay that the insurance company contracted with you for them to pay, then most insurance companies will consider this as fraud. They will view this as a kick back or an intice on your behalf to get patients to come to your practice. The only way a copay should be written off is if faith efforts were considered by the patient to pay the copay(after bills have gone out to the patient)and they have written a financial hardship letter with proof explaining that they can not afford the bill.

Medical Billing Schools

To obtain a career in medical billing, you do not have to take a course. Coding and billing are different from one another. Coding is linking a code to a diagnosis and cpt code. Remember a diagnosis (or dx for short) is the code that describes what is wrong with a patient and the cpt code is the code that describes what is being done. If you decide to become a coder then this is something that you should go to school for but billing is different. Alot of people think medical billing and coding are the same thing but they aren't.

If you don't have any experience in billing, try starting through a temporary service. They will help get you in the door through a front office assignment. Front office jobs are easier to start with. Example of a front office job is taking patient copays and setting up appointments. From here you can easily get office training on other billing functions and in no time you can start your career in medical billing.

Insurance Follow Up

When a claim is outstanding and there is no response from the insurance company, we need to call the insurance company to check the status of the payment or denial. When doing follow up, the insurance company will ask for your name, number, tax id, provider names, pt name, policy #, date of service, date of birth, charge amount and sometimes providers address.

Example we’ll use

Tax id 52-1234567
Provider Dr. John Jones
Provider Address Po Box 1234, anywhere city, state, zip
Policy number 256RL6523
Pt name, Jill Jackson
DOB 11-01-1955
DOS 1-12-2006
Charged amount $300


Example call:
ABC Insurance Co: ABC Insurance Co Lisa speaking can I get your provider #
You: 52-1234567
ABC Insurance Co: Who am I speaking with?
You: Amy
ABC Insurance Co: Is there a call back number for you.
You: 410-555-1212(this is your office number)
ABC Insurance Co: What is the name of your provider?
You: Dr John Jones
ABC Insurance Co: Patients name and DOB
You: Jill Jackson 11-1-55
ABC Insurance Co: And the Patients policy number?
You: 256RL6523
ABC Insurance Co: DOS and charged amount
You: 1-12-06 $300
ABC Insurance Co: Thanks, how can I help you?
You: I need to know the status of payment
ABC Insurance Co: Ok I’ll check the status for you.
You: Thanks

The insurance company will either tell you when the claim was paid or tell you if it was denied.

New HCFA Forms

New HCFA Forms are coming. Are you ready? Eventually anyone sending claims on the old HCFA1500 forms will start to reject. To read more about the changes visit this website. http://www.nucc.org/

Learning Health Insurance for Medical Billing

HMO- (Health Maintenance Organization)- most non emergency treatment needs PCP, normally requires referrals to go to different specialties.

PPO- Preferred Provider Organization- a selected network of providers. Usually no referrals required. Usually have copays.

POS- Point of Service- a hmo plan with option to opt out of network without a referral for a higher fee.

Indemnity Insurance- covers large amount of network providers. Pt Usually have a 20% coinsurance.

Government Programs-(to help assist the elderly, disabled and low income)
Medicaid- funded by the state. No fees to the patient
Medicaid Family Planning Only(visits related to contraceptive management)
MCO-Medicaid HMO or Managed Care Organization
CHIP (Children Health Insurance Program) no premium, no copays for pregnant women
and children.
CHIP premium- Low cost monthly premium to parents with higher incomes
Medicare- Normally for patients over 65, or young patients with disabilities or people
with End Stage Renal Disease.

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.