Medical Care Billing Basics: A Step-By-Step Approach

Transcription

1 Slide 1 Medical Care Billing Basics: A Step-By-Step Approach Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, COBGC, AHIMA Accredited ICD- 10 Trainer, AHIMA ACE mentor 1

2 Slide 2 Introduction to Billing Basics I will be presenting information regarding the Biling basics for private physician based, and outpatient based medical practices. I will help you understand the basic functions of the billing processes from the time the patient calls for an appointment, to the completion of the service, when all payment is received. Today s session will provide information in an easy-tounderstand format for medical personnel who are not familiar with the billing processes within the medical office practice/physician practice 2

3 Slide 3 Learning Objectives Pre-service Workplan - Getting background information on your patient preparing for the appointment Acquiring the minimum basic billing information getting it right the first time Patient Payments what you should collect at the time of service Documentation and Claim Submission 3

4 Slide 4 Overview All the puzzle pieces need to fit together Provider Insurance Payers Documentation Patient Co-Pay Deductibles HIPAA Clearing House Denials Appeals 4

5 Slide 5 Let s get started! The Patient accesses your office or practice to schedule an appointment Telephone Walk In Referral from Friend/Media 5

6 Slide 6 The patient schedules an appointment with the Patient Services Representative either in-person, via phone, or electronic media Verification of insurance Authorization and certification to see provider (depending upon the carrier) Pre-registration gathering of demographics Identification of referring physicians or consultants Patient is informed of the referral process, and instructed to bring all insurance cards and copayment amounts 6

7 Slide 7 When possible, have the patient complete the demographic, registration and consent forms in advance by Mailing, faxxing, or these blank documents to the patient Have the patient bring the completed forms with them to the appointment If patient unable or unwilling to do this in advance, consider having office personnel do this with the patient over the phone prior to the appointment 7

8 Slide 8 Before the patient arrives, do a quick pre- verification of insurance Ensure that any preauthorizations are on-file and completed prior the patient s arrival 8

9 Slide 9 APPOINTMENT DAY! Review all demographic information with the patient Make a hard copy or electronic scan of the patient s insurance card. Collect any prior balances, co-pay or deductible s $ s as appropriate 9

10 Slide 10 Patient meets with the provider for care of documented services Patient is seen and examined regarding identified medical concerns ro problems Procedures are performed and/or treatment prescribed or initiated Final diagnosis is noted Physician or provider of care documents the services rendered within the medical chart/record. This is to be appropriate and correct and informative for the patient. 10

11 Slide 11 Patient has completed the appointment with the provider Review with the patient any billing concerns, Provide the patient with an estimate of the charges for the day s visit Remind patient of any follow-up care needed and schedule those appointments or services at the time of exit. 11

12 Slide 12 The provider/physician documentation is reviewed and coded The services documented by the physician or provider is reviewed by the office biller/coder to accurately reflect services utilizing CPT, ICD-9 and HCPCS codes. Documentation is completed and signed off by the physician or provider 12

13 Slide 13 The charges are keyed and processed Biller/Keyers/coders will enter the billing data into the patient management system to include all fees Once entered, the claims management software should initiate a scrub of the coded charge entries for correctness Charges are to be entered in a timely manner for prompt payment by 3rd party payers In a best practice your charge entry should happen within 1-2 days 13

14 Slide 14 Claims and statements are produced Claims are created by the billing software and edited to be complete and correct (an additional scrub) Claims are then sent electronically to the payer, or the insurance clearinghouse daily. Goal is to have 100% of all claims go electronically initially. Only appeal claims should go out via a paper process Billing statements are sent out to patients with a self pay balance 14

15 Slide 15 Once Claim is received by the 3 rd party payer, they will remit payment to the provider and include information regarding the adjudication of the claim Manually key the 3 rd party payments, denials, rejections and or adjustments as per what is noted on the remittance advice from the 3rd party payers Create and document any and all refunds to be sent back to 3rd party payers or patients. All refund activities should be processes within a designated time frame (such as 1 week, once per month etc) Reconcile all charges, payments and adjustments at the end of the day, or within a 24 hour time period. 15

16 Slide 16 If your claim is not paid, the claim needs to be sent back to the 3 rd party payer for for resubmission and/or appeal Review all remittance advice, for rejections. Make all coding and charge corrections (if warranted by documentation) Correct any demographic errors, or missing referral/pre-authorization numbers Review bundling edits and adjustments 16

17 Slide 17 Secondary claim is filed (if necessary) Have biller/coder submit claim to secondary/tertiary payers. The goal for this should be within 1 week of receiving initial claim. Most Medicare plans will automatically medi-gap the claim to the secondary/tertiary payers. If initial claim is rejected, have appeal letter created, and submit with appropriate documentation and forms Re-submit and appeal with hard paper copy, or via electronic submission if possible. Follow up on all re-submitted claims within a 30,45,60 timeframe process. If the unpaid claim is older than 75 days, move to self pay balance and contact patient regarding the non-payment of the claim by their insurance carrier. 17

18 Slide 18 Follow up with the patient!! Initiate an in-house collection call for self pay accounts and/or unpaid insurance claims within 30,45,60 day periods or a timeframe that is comfortable with your office s revenue stream. Create payment arrangements or a budget plan for outstanding balances that exceed XXX dollars. 18

19 Slide 19 Problems and Pitfalls Some of the pitfalls of the revenue cycle are high deductibles self pay patients charitable contributions peaks and valleys such as cold and flu season, holiday seasons restrictive processes such as preauthorizations and referral issues. ** Your front desk personnel should be well versed in the on-going collection of co-pays and deductibles at the time of service ** 19

20 Slide 20 Problems and Pitfalls Within the revenue cycle, you need to make sure that your electronic claims submissions, or clearing house follow the most current submission protocol (CMS Version 5010) Use the most current hard copy and electronic forms/formats that are available. Currently CMS requires physician practices to file claims on a CMS 1500 form, and facilities for file claims on a UB- 04, 20

21 Slide 21 Problems and Pitfalls Common Payer Denial reasons Patient Demographic Information is incorrect on the claim. Non-Coverage or Terminated Coverage, or Member is not found on file at the time of service Pre-authorization or Certification not on file, No referral on file CPT/ICD-9/HCPCS issues. Make sure that your staff is using the correct code sets and informatin 21

22 Slide 22 Common Payer Denial reasons Internal software system errors such as a missing UPIN or NDC number, or physician ID numbers Claim denied for a third party liability marker, such as a workman s compensation carrier, or motor vehicle accident carrier claim Be sure to file your claim within the timely filing deadline 22

23 Slide 23 Audit your internal processes It is always a good idea to look at how your staff is performing and do a quick but comprehensive overall office audit to include: Review your Fee slip/superbill/encounter sheet for correct codes/pricing Audit the percentage $ s collected at time of service by front office personnel Do a top-10 procedures audit to ensure that you are onpar with the 3 rd party payers your contract with Audit your medical records to verify that signatures, consents, waivers, and ancillary reports are on filed, and correctly filed within the chart, and all have been billed in a timely manner (charge lag/missed billing) Follow up/appeals audit. Look at the denied claims that you have appealed and formulate a percentage of those that were successful appeals vs/unsuccessful appeals to the carriers 23

24 Slide 24 Last but not least Staff & Personnel Issues Ensure all staff are educated for the duties and job functions needed for their role in the office Ensure the staff have adequate tools to perform their jobs (i.e. coding books, fax, e- mail, internet access) Ensure that your billing software or clearinghouse are utilizing the most current electronic formats Ensure that the hard-copy billing forms (CMS 1500 and UB-04) are the most current, and all are filled out correctly. 24

25 Slide 25 THANK YOU! Please join us for additional billing education seminars CMS 1500 * Understanding the form, and what information is required for submission UB-04 * Understanding the form, and what information is required for submission Visit for dates and more details regarding these and other webinars. 25