Navigating Through a Multiple Payer Environment – Providers’ Perspective

Healthcare delivery in the United States of America has come a long way from cash-based to insurance-backed. Currently, over 85% of the nation’s residents have health care plans either through employers’ private pools, private companies, the veterans’ health administration, the children’s health insurance program and Medicare/Medicaid /TRICARE. While insurance payers (whether Federal or private) essentially cover health risks of the insured, they differentiate themselves with their respective restrictive operational requirements. The impact of this restrictive payment environment is such that health care providers are increasingly finding it difficult to procure their payments on time. And, with the Federal Government inclined to make health insurance mandatory, care providers’ only hope is to find a way to deal with multiple regulatory insurance payers.

Unlike United Kingdom and Canada, which have single-payer system, US is characterized by Federal and Private Payer systems. And Federal system is again sub-divided into Medicare/Medicaid/TRICARE.

The majority of insured Americans receive their health care (insurance) coverage via a private insurance company. Currently in the country, 59.3% of all insured Americans have coverage through private insurers. These private insurance holders can once again be classified under:

• Group insurance, which is availed through an employer with provision to cover spouses and children, based on the particular package
• Individual Insurance, which is purchased by the insured himself to cover his or his family health risks
• Managed-care plans: The two most popular types of managed-care plan providers in America are Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs). An HMO plan will have a predetermined facility and doctor for you and/or family. When you need treatment, you will have to visit the contracted facilities and see the contracted physicians in order for the insurance to pay the bill

With so many variants of private healthcare policies, healthcare providers usually have a hard time understanding and billing with private payers. The stress is so much that it is actually started to impede their clinical efficiency, which is their main concern. There is a whole lot of stressful restrictions that providers will come across, such as:

• dealing with deductibles and copayments,
• establishing medical necessity of a procedure
• dealing with preexisting conditions

Though dealing with Federal Payer system is relatively less difficult, providers have to deal with state-specific rules that govern Medicaid/Medicare:

• With the Federal Government hinting at extending Medicare base from the current 28%, providers will have more Medicaid/Medicare supported visitors
• Federal Government entertains Medicaid/Medicare beneficiaries’ bills from only a few designated providers. Therefore, care providers have an overriding duty to check insurance authorization prior to administering medical services
• Further, Medicare/Medicaid is also bound by restrictions on repetitive, pre-existing, and quantum of admissible medical expenditure to its beneficiaries

If understanding multiple payer system and their respective restriction constitutes half of the battle, billing and coding in ICD-10 and HIPAA 5010 Version will constitute the other half. But, providers, with their clinical efficiency at stake, would do well to assign these operational issues to external billing consultants.

Medicalbillersandcoders.com with credible history of helping physicians realize maximum claim realization amidst multiple payer environment – will help make the task a lot easier. Our medical billing professionals are highly trained and certified with experience in handling multiple payer environment and the latest coding practices. Their expertise combined with our technology edge is a sure way to turnaround your practices’ revenues.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Healthcare Systems Adopt Trend of Outsourcing in the New Era of Value-Based Care

In the time when both, federal and provincial healthcare quality initiatives have come up with healthcare reforms, thus making EHR mandatory in order to avail the incentives under ARRA, the compliance with Medicare Medical Billing norms, demand of documentation under Medicare’s Accountable Care Organisation (ACO) model and the transition of both ICD 10 and HIPAA 5010, health care documenting in healthcare would probably never be the same. Though these reforms have been introduced with the sole aim of increasing the clinical and operational efficiency in healthcare organizations, the physicians have a lot to cope up with and this can hinder them from focusing in their function of providing medical services.

In the era of value based care, physicians find it tough and time consuming to balance administrative along with their prime function of patient care on their own. Outsourcing the administrative processes which needs expertise and resources is significantly more appropriate approach when these aren’t available in house. Health care organizations and physicians are increasingly seeking contractors for services like billing, coding, medical staffing and information technology services in order to bridge the gap. The companies providing these services have no doubt proved to be beneficial for the growth of its clients. Moreover, it has been found that the growth in outsourcing between the 2010 and 2011 was reported to be around 13.1% with 20 outsourcing firms which served 16,463 clients.

Benefit of Outsourcing

Partnering with an outsourcing firm has brought more technology and expertise in the industry, thus expanding the job options in the field, along with helping physicians extract most of the money for the services they deliver.  Contrary to the popular belief that the small healthcare firms do not need outsourcing, truth is small facilities too are finding it beneficial to outsource as they adopt electronic billing and EMR implementation along other reforms in the new era of value-based care.

Outsourcing the task of medical billing relieves the medical professional from various administrative tasks. The health care organization can be saved from a few issues which are unavoidable like:

• Staff retention: with the outsourcing process, healthcare organization need not worry about recruiting, managing & retaining billing staff and training new billing staff  when old staff retires or moves on, hence helping in smooth functioning of the billing process
• Billing possible on all days: with in-house billing there is complete dependency on fixed staff members and in case of absence of any of the staff members or any holiday, the billing process is kept on hold, but with outsourcing this headache is eliminated ensuring on-going billing process throughout the year

Outsourcing can make your office run more efficiently and systematically with small investments which although go unnoticed, but are considerable in total like postage charges and telephone bills also reduce. Added costs for labour, office system and other operational expenses are also reduced considerably. Furthermore a better turnaround time with better revenue cycle is guaranteed along with improved collection rate on an average of nearly 20%.

MedicalBillersandCoders.com the biggest consortium of billing and coding experts, has been assisting medical practitioners and health care workers for over a decade now towards betterment of revenue cycle and management of administrative tasks. Our billing and coding experts are also constantly trained and updated with the latest reforms, thus rendering the clients stress free and relaxed as far as revenue is concerned.

How are Physicians Expected to Bill Post Implementation?

Even though ICD 9 and ICD 10 are very similar in many ways including the guidelines, rules and conventions used which consequently brings out similarity in the organization codes as well; ICD 10 is a product of many improvements done in ICD 9 coding.

In spite of the overwhelming improvements, the transition from ICD 9 to ICD 10 has been a huge challenge for the physicians, medical billers and health care workers to catch up with the advancements. Also the staggering number of new codes has made the learning process a tad complex along with complicating the coding process, making the claims susceptible to errors and vulnerable to denials. This is further exacerbated by difficult denial management.

According to the new proposed rules from Department of Health and Human Services, health care professionals would be required to bill their services using ICD 10, with effect from October 1, 2014. This date has already marked the one year extension to the previous date of October 1, 2013. Along with the introduction on 5010 new electronic codes, the physicians are also expected to meet a few other health and quality information technology initiatives like adopting electronic health records and participating in physician quality reporting system.

With the number of codes skyrocketing from 17,000 to around 140,000, healthcare providers along with their medical billers and coders need to pull up their socks in order to avoid having any problem with insurance reimbursements and denials. According to the official website of CMS, compliance date for implementation of ICD 10 is October 1, 2014 with no grace period or further delay expected, however they have not yet mentioned grace period for billing under ICD-9 without penalty post October 2014.

Nonetheless the transition period would pertain roughly for two years during which the coders would have to work simultaneously with both, ICD 9 and ICD 10. At the same time, the billers would be required to train with new set of procedures and policies, in absence of which the employer might result in lowered productivity in the future. The billers also need to learn about the policies introduced for payment reimbursements along with the new ANSCI reposting methods and electronic formatting procedures.

Medical Billers and Coders with ICD 10 implementation will additionally need to possess a more detailed knowledge of the anatomy, physiology and medical terminology and also work in close association with the doctors and educate them about the proper coding methods.

Also as mentioned earlier with no further delay expected, medical practitioners need to catch up with the new reforms; to avoid as much as possible any chance of decreased cash flow. With a possibility of increasing call volume for denials and rejected claims along with increased billing audits, it is advised that physicians take the next step towards ICD 10 transition soon.

MedicalBillersandCoders.com serving healthcare for more than a decade now have already initiated a unique ICD 10 training program which helps coders and billers get updated with the latest ICD 10 developments and reforms. Our billers and coders are already preparing for this transition as our training program endeavours to positively help you, as a medical coder and biller to remain at your competent best when the times change from ICD 9 to ICD 10.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

How are Physicians Expected to Bill Post Implementation?

Even though ICD 9 and ICD 10 are very similar in many ways including the guidelines, rules and conventions used which consequently brings out similarity in the organization codes as well; ICD 10 is a product of many improvements done in ICD 9 coding.

In spite of the overwhelming improvements, the transition from ICD 9 to ICD 10 has been a huge challenge for the physicians, medical billers and health care workers to catch up with the advancements. Also the staggering number of new codes has made the learning process a tad complex along with complicating the coding process, making the claims susceptible to errors and vulnerable to denials. This is further exacerbated by difficult denial management.

According to the new proposed rules from Department of Health and Human Services, health care professionals would be required to bill their services using ICD 10, with effect from October 1, 2014. This date has already marked the one year extension to the previous date of October 1, 2013. Along with the introduction on 5010 new electronic codes, the physicians are also expected to meet a few other health and quality information technology initiatives like adopting electronic health records and participating in physician quality reporting system.

With the number of codes skyrocketing from 17,000 to around 140,000, healthcare providers along with their medical billers and coders need to pull up their socks in order to avoid having any problem with insurance reimbursements and denials. According to the official website of CMS, compliance date for implementation of ICD 10 is October 1, 2014 with no grace period or further delay expected, however they have not yet mentioned grace period for billing under ICD-9 without penalty post October 2014.

Nonetheless the transition period would pertain roughly for two years during which the coders would have to work simultaneously with both, ICD 9 and ICD 10. At the same time, the billers would be required to train with new set of procedures and policies, in absence of which the employer might result in lowered productivity in the future. The billers also need to learn about the policies introduced for payment reimbursements along with the new ANSCI reposting methods and electronic formatting procedures.

Medical Billers and Coders with ICD 10 implementation will additionally need to possess a more detailed knowledge of the anatomy, physiology and medical terminology and also work in close association with the doctors and educate them about the proper coding methods.

Also as mentioned earlier with no further delay expected, medical practitioners need to catch up with the new reforms; to avoid as much as possible any chance of decreased cash flow. With a possibility of increasing call volume for denials and rejected claims along with increased billing audits, it is advised that physicians take the next step towards ICD 10 transition soon.

MedicalBillersandCoders.com serving healthcare for more than a decade now have already initiated a unique ICD 10 training program which helps coders and billers get updated with the latest ICD 10 developments and reforms. Our billers and coders are already preparing for this transition as our training program endeavours to positively help you, as a medical coder and biller to remain at your competent best when the times change from ICD 9 to ICD 10.

How difficult can medical claim filing and payment posting be?

Hospitals, healthcare organizations and dentists have long been occupied with the issue of medical filing. The process of medical claim filing is overtly complex, requiring paper work, filing and adjudication. Moreover, with the introduction of new reforms in the system every other day, which is ironically meant to save time and energy of the physician, is a reason for increasing problems until physicians manage to successfully make the required changes.

Hence more documentation, additional reform requisites requires more administrative staff. At times, the ratio of staff dedicated to handle the paperwork to doctors can even be as high as 1:12. Organizations can end up making 19 copies for every document, for which they have to spend $20 in labor to file these documents. However, 1 in every 20 documents gets lost due to glitches in administration. The increasing documentation requires attention and efforts from physicians as well, which makes it difficult for them to concentrate on what they are supposed to be. Hence, it also leads to the shortage of doctors in the healthcare organizations.

With the electronic filing of the claims made mandatory with HIPAA, it will benefit physicians due to lesser paperwork, but physicians now need to update their systems with the right software to file claims electronically. Also it has become crucial for the physicians and coders to be trained in ICD 10 for future filing of claims. Moreover recently in an event of aberration, the claim has a high chance of being rejected and the physician has to repeat the process all over again. This invariably leads to time consumption and cost delays. Insurance payers recently have become increasingly stringent about the course of claims, thus directly afflicting the physicians and their revenue procurement.

Hiring a trained and professional medical biller and coders services can provide a breakthrough for the physicians from all of these problems. The professional medical biller and coder possesses sound knowledge about the rules and regulations regarding medical coding including constantly changing updates, regulations and compliance. Issues like claims denial, medical necessity, bundling issues and charge capture can be handled by them efficiently.

Reforms like HIPAA which are actually designed to protect the privacy can actually be a reason for major concern among the healthcare organizations. They require claims to be filed only electronically, which is undoubtedly a fast method, but besides challenges like converting to system of electronic payments, there are times when the electronic claims get rejected because of lack of petty things like right payer number, provider’s pin number etc. These issues, although seem to be minor, may end up in over extended deadlines and a loss of revenue to the organization. In this scenario, presence of a specialized billing service may help avoid such problems in the organization.

Medicalbillersandcoders.com, the largest consortium of medical billers and coders has been catering to the healthcare industry with its skilled and experienced billers and coders who simplify these processes for you and help in smooth functioning of your organization. Physicians form over 50 US states have been outsourcing their medical claim filing to MBC and are now confident about maximising their revenue cycle and managing their funds through MBC’S billing service.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Managing HIPAA Issues at your medical practices

With the application of HIPAA, (Health Insurance Portability Accountability Act), health care organisations need to be cautious with whom to share the patient information. HIPAA calls for protection of the individual’s health information, at the same time; this privacy rule also permits limited disclosure of health related information to related entity of a person who needs patient care, thus, bringing on added responsibility for the staff.

Challenges faced: Introduction of HIPAA has proved to be a challenge for medical billing over the recent years with providers required to send claims electronically in compliance with the act, in order to receive their payment. Medical billing and insurance companies have both been affected because of the regulations imposed by HIPAA requiring additional waivers and increased documentation related to HIPAA. Moreover billing software used along with business processes – practice management service vendor, billing system and clearing house – also need to be re-looked so as to become compliant with the HIPAA.

Benefits to medical practice due to HIPAA: Efficiency and cost savings are some of the many advantages of using HIPAA standard transactions:

• Electronic claims: the HIPAA rules require the Medicare claims to be submitted electronically. Most of the providers are able to electronically claim directly to their insurers
• Patient satisfaction: an efficient HIPAA compliant billing system ensures patient information privacy hence improving patient satisfaction and in turn patient count for the physician

Electronic claims have proved to be a giant leap for the health care industry. Huge gains have been estimated by the analysts by implementing the transactions as per required by HIPAA.

Current move to HIPAA 5010: According to CMS Physician offices are seeing reductions to their revenues after the move to HIPAA Version 5010. Industry experts feel problems due to this transition has affected physicians, billing clearinghouses, and public and private insurance payers as well. There has also been a lack of uniformity with certain practices billing using the older HIPAA 4010 standards, with some health plans adjudicating those claims while some clearinghouses are automatically converting 4010 transactions into the 5010 format for payment.

Streamlining your billing system: Getting a separate billing system for your medical practice can be prove to be beneficial as being specialists in their field they can easily perform assessments of your practice, using the latest HIPAA regulations and standards, also improving the revenue cycle- leaving enough time for the health care staff to do their job and physicians to solely concentrate on patient care.

Medicalbillersandcoders.com billing for more than a decade now play an indispensable role in confirming to HIPAA while billing for health care organisations. They make sure that individually identifiable information on health is protected and there is no violation of the act. MBC serving various specialities in healthcare is constantly updated with all billing reforms along with HIPAA norms while billing, helping health care professionals to concentrate on their core job of patient care, rather than worry about proper implication of HIPAA and other reforms.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies  in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services  according to their preferences of specialty, city, software and services performed.

Medical Billing Partner: A Strategic Avenue for Achieving Revenue Integrity?

Healthcare providers in the current environment are aware of the fact that every step counts, leaving no room for errors as far as securing the revenues and reimbursements are concerned for their services. However, as the procedure of patient billing information has been traditionally managed by different departments in isolation, showing little integration the deficiencies of one department might impact the other department adversely, and even damage the revenue cycle of the healthcare provider, hence providers are now in need of a strategic avenue to procure the right revenue for their clinic.

Processes like medical billing, collections and denials managements are some of the prime activities handled by the health care providers, which play a significant part in ensuring revenue optimisation. However payment accuracy, resolving cases of denials and managing the underpayments are specifically critical in order to maintain the healthy bottom line. Additionally healthcare reforms like – Electronic Health Recording (EMR) mandatory for securing incentives under ARRA, transition to HIPAA and ICD-9 to ICD- 10, though improving quality of care are also slowing down the Revenue cycle. All in all physicians have very little option but to re –organize their clinics entire billing process.

Medical billing partners being specialists in their field provide a practical and optimum choice for improving the revenue cycle, streamlining medical billing functions, ensuring optimal reimbursements, operational efficiency and compliance, thus helping the physicians and health care providers to achieve revenue integrity. Billing partners regularly check for any coding errors adding any modifiers if necessary thus negating any chance of discrepancy in the billing process. Problems like denials and underpayment can also be dealt with on the same platform, as billers assist in helping streamline changes to the clinic due to health care reforms providing experts who are well versed with ICD-10, HIPAA & knowledge about the EMR software suitable for your clinic.

RCM of a health care provider being quite complex, involves various processes and people, ranging from scheduling the patient to billing for the services and collection. MBC through it medical billing services has been helping physicians who are at a constant risk of losing considerable amount of revenue where lack of communication between various departments and inefficiency are common features. Medicalbillersandcoders.com has been involved in revenue maximization for healthcare organizations by billing and coding for over a decade now for physicians across the 50 US States and across varied specialties.

Our team is constantly training and updating themselves about industry requisites also providing consultancy right from the best EHR– to data analytics. At MBC our medical billing and coding experts are constantly striving to update themselves to achieve the right revenue for your organization.

Medical Billers and coders (MBC) is one of the leading Medical Billing Companies in USA & help doctors to shortlist Medical Billing Companies, Medical Billing Services according to their preferences of specialty, city, software and services performed.