Combining Medical Billing and Coding to Deliver Maximum Physician Revenue

'Medical billing’ and ‘Medical coding’ may have sometimes been used interchangeably to mean the act of claiming reimbursement from insurance payers, but essentially they are two separate and specialized jobs. Medical coding precedes medical billing, and it is irreversible. While a medical biller is entrusted with far more task than a coder, it is the quality of coding that largely decides the success of medical billing. That is why medical coding is often termed as a ‘specialty’ by itself while medical billing, its ‘sub-specialty’.

Medical coding is based on the descriptive narration of the medical services or procedures done by physicians. The coder assigns appropriate codes based on the physicians’ clinical summaries. Here, he may have to verify with diverse source points to validate the correctness of the physician summaries. Typically, he may have to rely on the transcription of the doctor’s notes, ordered laboratory tests, requested imaging studies and other sources. Such verification is necessary in avoiding denial, delay or exposure of claims to payer audit remarks.

Coder’s general responsibility is restricted to assigning CPT codes, ICD codes and HCPCS codes to both report the procedures that were performed and to provide the medical biller with the information necessary to process a claim for reimbursement by the appropriate insurance agency/s. But he may also be required to audit and re-file appeals of denied claims. In certain cases, coder may also educate providers and recommend the appropriate application of federal mandates and compliance that require providers to use specific coding and billing standards through chart audits.

Medical billing, on the other hand, is a series of activities culminating in ensuring maximum reimbursement for physicians. A medical biller job begins with filing insurance forms in the admissible formats with the payers. He may be required to clarify diagnoses or to obtain additional information so as to substantiate physician claims for reimbursement from payers. Like coder, he should also be familiar with CPT; HCPCS Level II and ICD CM codes to help him better understand the clinical summaries.

Apart from preparing invoices, medical biller may even be involved in rectifying past error on account of coding discrepancies. Collecting payments, making adjustments, interpreting Explanation of Benefits (EOBs), and handling denied claims, and processing appeals are all part and parcel of a biller’s routine.

Irrespective of whether coding and billing are done separately or by the same individual/s, the success of physician reimbursements depends on how best they complement each other. While medical practices used to manage coding and billing as a comprehensive internal function, it later started impacting their core function – clinical efficiency. Therefore, outsourced coding and billing became the accepted practice. And, with the US health care industry embracing its biggest billing and coding transition (ICD-10), along with the other reforms affecting the industry physicians’ reimbursement rates may further be impacted. Therefore, finding competent billing and RCM service providers makes much more sense than embarking on costly in-house practices, which may or may not yield the desired results.

Medicalbillersandcoders.com – with demonstrated ability in ensuring maximum reimbursement for a large pool of physician practices across the 50 states in the US – should be your first choice of billing and RCM services. Capable of maneuvering through multi-payer and ICD-10 environment, our billing services live up to being the most comprehensive with Patient Enrollment, Insurance Enrollment, Scheduling, Insurance Verification, Insurance Authorizations, Charge Entry, Coding, Billing and Reconciling of Accounts, Denial Management & Appeals and Physician Credentialing services.

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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.

Navigating through Regulatory Changes that Dramatically Affect Medical Billing

The limited reach of US healthcare network leaves a large part of American population outside the net of healthcare. This problem has stalked US governments traditionally and to expand the reach of healthcare to make healthcare available to a larger part of US population, successive governments (in varying degrees and as suited their political beliefs) have introduced regulations to make healthcare cheaper for and easily accessible to the care receiver.

In continuity of this tradition, the last few years under Obama administration have been witness to a flurry of regulations. Whilst one can argue that they have addressed the traditional concerns and empowered US healthcare to stand up to the challenges of technology and needs of modern day healthcare, the regulations have also affected the day-to-day healthcare operations carried out by medical practitioners coiling up every treatment procedure with regulatory activities burdening care providers with activities they neither have time nor qualification to perform.

The Affordable Care Act will expand the number of insured people by more than 30 million people. To restrict the increasing cost of Medicare, the act will create a panel of experts to prevent reimbursing for treatments not found effective and create incentives for healthcare providers to offer bundled payment modules to care receivers.

These are indeed very effective measures to take healthcare to lower income groups in the US and reduce healthcare costs, but they throw considerable operational challenges to healthcare operators. The effect of increase in number of insured Americans from a care provider standpoint is quite simple to understand: it will mean more regulatory responsibilities for care providers in way of having to deal with technical details related to billing and coding, using codes appropriately, etc., leading to not just time spent by them on nonmedical activities but also exposing them to the prospect of inaccuracies in preparing insurance claims resulting in claim denials.

However, the bundled payment aspect warrants a deeper look to understand the impact of regulations on day-to-day healthcare operations. A treatment episode is a sprawling affair. It includes various phases of treatment an individual goes through from pre-hospitalization diagnosis through hospitalization to post hospitalization care. Each one is a distinct healthcare activity and traditionally has had separate healthcare fees. Bundled payments club together the different fees associated with each phase of a treatment episode and offer the care receiver one fee for the entire treatment life-cycle, saving him money.

Albeit, this everything-rolled-together approach requires sound coordination among various specialties involved in a treatment episode for data sharing and final pulling together of medical information to prepare claims using appropriate codes for each phase of treatment. Big healthcare bodies have addressed some of these concerns (like internal coordination and easy availability of medical data while preparing claims) by making all the services available under one roof but are struggling with others, like using appropriate codes and spending resources (time and money) on non-medical activities, all leading to low rates of claim reimbursement and revenue leakage. Finding it difficult to withstand the financial onslaught wrought by denied claims and losing patients to big care providers, small operators have aligned themselves with big care providers losing their entrepreneurial independence.

Coping with the changes caused to medical billing:

The irony of this whole US healthcare industry saga is that what has caused this is not a healthcare issue but an administrative one. To handle this issue, a care provider either needs an in-house setup with a strong revenue management system staffed by well-trained billers and coders to handle the entire claim preparation process using appropriate codes and medical details where necessary and knowledge of software platforms to submit the claims electronically to ensure HIPPA compliance or needs to outsource the entire claim administration process to a biller and coder.

Medical Billers and Coders, the largest billing and coding consortium in the US,  has helped care providers in all 50 states of rural and urban US to address these issues helping them to save time and cost, an advantage they can divert to their core business, healthcare, and also share with the customer. MBC’s experienced billers and coders are familiar with all regulatory details and prepare claims with high degree of accuracy ensuring low rejection rates.

MBC can also spruce up your revenue management cycle by pruning up your processes, replacing your old software platforms with new and appropriate ones and training your staff in administrative details as also cross-functional competencies thus reducing your downtime and ensuring the continuity of your billing process in the absence of a staff.

Increasing Revenue through HIPAA Compliant Practices

HIPAA (Health Insurance Portability and Accountability Act), which was first enacted in 1996 to improve the efficiency of healthcare delivery, has come to be recognized as the standard for  electronic data interchange (EDI), security, and confidentiality of all healthcare-related data.  The Act mandates: standardized formats for all patient health, administrative, and financial data; unique identifiers (ID numbers) for each healthcare entity, including individuals, employers, health plans and health care providers; and security mechanisms to ensure confidentiality and data integrity for any information that identifies an individual.

Healthcare providers exchange healthcare data for a variety of purposes: collaborative clinical management, national healthcare planning, and more importantly for medical billing. Medical billing is a series of tasks comprising claims submission, charge entry, denial management, payment posting, tracking of accounts, appointment scheduling and rescheduling, billing and reconciling of accounts, patient enrollment, patient scheduling and reminders, financial management reporting, AR management (insurance and patient),  medical coding audits, insurance verifications; insurance authorizations and follow up of rejected claims. The sum total of these tasks is collectively called Revenue Management Cycle (RCM).

Providers at each of these RCM task are required to follow HIPAA norms. One of such predominant norms is electronic processing of billing and coding in accordance with the HITECH’s meaningful use criterion. Failure to comply may invite mandatory data breach notifications, heightened enforcement, increased penalties and expanded patient rights. The cumulative effect of these impositions may unduly delay claim realization, thereby affecting practice revenues. Providers may even face intense audit and scrutiny, which may be detrimental to their credibility and sustenance in a highly competitive healthcare industry.

Therefore, it is advisable that providers’ outsource proven, web-based framework that allows them to collaboratively manage their HIPAA/HITECH Act compliance initiatives including HIPAA Audits and HITECH Privacy Breach Management using a single, integrated solution. Using such robust system (an integrated EHR with EMR and PMS), they will be able to perform the entire range of clinical and operational functions in sync with the HIPAA norms. Once they have their clinical and operational functions (billing included) on the right track, it will be easier to expect unhindered and fast realization of claims. The advantage of engaging a HIPAA-compliant outsourcing company is that it assures confidentiality of patient and practice information in accordance with the norms laid down by the Health Insurance Portability and Accountability Act (HIPAA). This helps avoid unnecessary litigation and maximize claim reimbursement.

Medicalbillerandcoders.com comes across as a trusted name in HIPAA compliant medical billing and RCM services. For over a decade, we have been helping healthcare providers (across the 50 states in the US) realize maximum revenues through reliable HIPAA compliant practices.

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.

Billing “Urgent Care” As It Emerges As One of the Fastest Growing Specialties

Urgent care is fast developing as a viable alternative to what has traditionally been known as “family practice”. The main reason behind this new-found fancy is that physicians can now operate from designated facilities without having to trek around offices, nursing homes, and hospitals. Additionally, urgent care centers are preferred to other similar types of ambulatory healthcare centers, such as emergency departments, and walk-in primary care centers by the scope of illness treated and facilities available on-site. It will not be long before we witness further addition to already 8,700 urgent care centers (UCCs) across the US.

While it is true that practicing Urgent care offers physicians an extended scope and avenue for revenue generation, there are certain criteria (established by The Urgent Care Association of America) that physicians must abide by. These criteria describe scope of service, hours of operation, and staffing requirements. A qualifying facility must treat walk-in patients of all ages during all hours of operation. It should treat an entire range of illnesses and injuries, and have the facility to perform minor procedures. An urgent care center must also have on-site diagnostic services, including phlebotomy and x-ray. Because of this inclusive medical service coverage, Urgent care medical billing has become far more complex than usual. Urgent care physicians will be called upon to deal with:

• Code that allows urgent care centers to code and get reimbursement for the extra expenses involved in providing urgent care services
• Code that allows the urgent care center to receive reimbursement at one flat rate (Global Fees for services rendered at Urgent care centers) for all visits coded with it
• The usage of evaluation and management (E/M) codes as per EMTALA guidelines if it is a Type B emergency department
• Facility codes in urgent care
• National Provider Identifier (NPI)
• E/M Code plus Procedure Code in Urgent Care
• Level 1 E/M Code 99211
• Codes for services rendered during extended hours
• E/M Code + IV injection procedure code

Added to this complex coding is a reimbursement environment which has become more restrictive post a series of healthcare reforms recently. This additional burden of revenue cycle management (RCM) to an already overweighing clinical schedule may impede the very focus of clinical excellence. This is precisely the reason why physicians are turning to specialist billing and revenue cycle management from “urgent care medical billers”. Consequently, there has been an unprecedented demand for billers and coders in this domain.

At a time when the market is still peaking, Medicalbillersandcoders.com – the leading source for specialist billing and RCM services – has taken the lead in supplying the right billing and RCM sources to urgent care practitioners. Spread across all the 50 states in US, we provide experienced billing experts for urgent care billing & RCM for your medical practices.

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

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.