The Medical Billing Process
When a patient visits a physician, the doctor evaluates the patient and writes down the observed conditions and treatment. This information is then given to a medical coder who takes this information and assigns the appropriate ICD-9 diagnosis and CPT treatment codes (and code modifiers if necessary).

These codes are then entered on a superbill or patient encounter form. You’ve probable seen one of these when visiting the doctor. Many physicians don’t even use a coder and do this there self by checking or circling the diagnosis and treatment codes directly on the superbill. The majority of patient visits involve using a lot of the same codes.

This is when the medical billing specialist gets involved. They take the superbill and input the information into the practice management (or medical billing) software. Paper claims are printed out on a CMS-1500 insurance form and mailed to the insurance carrier. Electronic claims are sent electronically either directly to the insurance company or a clearinghouse.

 Medical Billing Errors
Healthcare claim processing errors keep a provider from getting paid. Here are some of the most common medical billing errors and suggested medical billing practices to prevent.

Medical Billing Collections
There’s two types of collections – Patient and insurance.

Patient Billing

Patient billing is the process of charging patients for amounts not covered under their insurance plan. Medicare requires the patient be billed for their responsible coinsurance or deductible amount. There are however Medicare patients who can be exempted due to documented hardships.

Most commercial insurance provider contracts require the patient be billed for deductibles , copay’s, and coinsurance so it’s important the provider understand this.

For our clients we’ll typically print statements and mail to the patients once a month. Most medical billing software programs have a feature for creating and printing these statements.

Sending out patient statements for a large practice with many patients can be very expensive. Many clearinghouses offer services to print and mail statements. All we have to do is print our statements to an electronic file and upload to the clearinghouse for processing.

This is a tremendous time saver. Stuffing hundreds of statements into envelopes is very time consuming and labor intensive. Not to mention the logistics of getting all those envelopes mailed.

Insurance Collections

Also referred to as aging. This is a tedious process which involves a lot of phone calls to insurance companies to determine why a claim was denied. Most insurance companies have an automated phone system that allows you to check status. However entering all those numbers via the phone keypad is tedious for a medical billing specialist. A lot of larger insurance companies may have the ability to check claim status on-line.

A good reason it is so important to get the claim right the first time and avoid all this work. In general the longer a claim goes unpaid, the harder it is to get paid.

Medical Billing Records
There is a lot of paper associated with billing and it has to be organized and filed. Frequently when working on secondary or tertiary insurance claims, we have to retrieve the primary EOB.

We also find it necessary to occasionally dig out an old superbill. It is very important to have and organized filing system. Otherwise you waste a lot of time looking for documents.

Write Appeals
A medical billing specialist may occasionally need to write a letter to the insurance carrier requesting payment for a denied claim. This is usually a letter with information such as claim number, date of service, provider identification number, patient group or policy number, why the claim is being appealed, and what action is requested.

Responding to Patient Billing Questions
I get some interesting phone calls from patients sometimes after statement are sent out. When a patient has a question you have to look up their account in the medical billing software and explain their charges. Sometimes they are not too happy about it.

I’ve learned to be patient and diplomatic when explaining a patient bill. Angry patients are actually very few – especially when the patient statement is formatted to be easy to read with good descriptions of the charges. For my largest practice we typically send out greater than 300 statements a month – and we might get one agitated patient every few months.

Run Reports
Doctors frequently want to know how their practice is performing financially. Most software programs have many useful pre-formatted reports that show a lot of useful information.

Having a software with the ability to customize and filter these reports is very helpful to the medical billing specialist. It seems like every provider has a different preference for practice information.

Working on insurance aging requires running an aging report. If the billing has been neglected this can be rather long.

Other Medical Billing Specialist Knowledge and Skills
Most smaller practices do not have a dedicated coder so it’s important to have some coding knowledge to be able to look up ICD and CPT codes and know how they are organized.

Understanding managed care authorization and coverage limits is necessary when investigating unpaid claims. Some specialties, for example mental health and physical therapy, have limits on the number of approved visits.

A medical billing specialist may be required to call and verify the number of authorized visits for a patient. We use our billing software to add reminder notes that pop up when the patient records are accessed to remind us and the front office receptionist.

Medical Billing Guidelines
It’s also important for a medical billing specialist to be familiar with the guidelines established by HIPAA to protect patient privacy and the OIG guidelines to prevent fraud.

Challenges Operating a Billing Service
This is my rant on the challenges of operating a physicians billing service. This billing services owner shares her thoughts on the demands and challenges in working with doctors and their medical office staff.

What Is Medical Billing Fraud?
Medical billing fraud contributes to rising health care costs for all of us. It’s any attempt to fraudulently obtain payment from and insurance carrier. Medicare and Medicaid are especially susceptible to fraud due to their payment arrangement.

ICD-9 Diagnosis Codes
Find out what ICD 9 codes are and their relationship to CPT codes. What are the best ICD-9 codes reference for the medical billing and coding specialist.

CPT Medical Billing Codes
Find out what CPT Medical Billing Codes are and their relationship to ICD-9 codes. What are the best references for the medical billing and coding specialist.

CPT Modifiers
CPT Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered.

Health Insurance Providers
Here’s a description of the many different health insurance providers and health insurance plans available.

Dental Insurance Billing
Dental Billing – How it differs from Medical Billing. The same principles apply to dental billing insurance as with medical billing.

Working for A Billing Service
Learn what its like to work at a medical insurance billing services company. Here’s an idea of what to expect based on my experiences both working for and owning and operating a medical billing company. This can be a great start for those looking for entry level medical billing jobs. That’s how I got started in this business.

Medical Billing Training
Becoming a successful medical billing specialist, whether getting a job or starting a business, requires training in the fundamentals of medical billing. One of the best and most economical options is MedicalBillingCourse.com.

They are Better Business Bureau accredited, offer nationally recognized certification, taught by medical billing professionals, and have a 100% satisfaction guarantee. Check out their course outline here.

Considering Starting A Medical Billing Business?
Starting a medical billing coding business requires wearing several hats. What to consider when starting a medical billing service business. Links to other helpful resources.

What is Medical billing?

Medical billing  is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider.

What is co-pay?

The copayment or copay is a payment defined in the insurance policy and paid by the insured person each time a medical service is accessed. It is technically a form of coinsurance

What is deductible?

An amount or period which must be deducted before an insurance payout or settlement is calculated

What is co-insurance?

An insurance policy provision under which the insurer and the insured share costs incurred after the deductible is met, according to a specific formula.

What is out of pocket expenses?

Out-of-pocket expenses are expenses that a health care plan does not cover. Learn about out-of-pocket expenses and the types of out-of-pocket expenses

AMA – American Medical Association. The AMA is the largest association of doctors in the United States. They publish the Journal of American Medical Association which is one of the most widely circulated medical journals in the world.

Aging – One of the medical billing terms referring to the unpaid insurance claims or patient balances that are due past 30 days. Most medical billing software’s have the ability to generate a separate report for insurance aging and patient aging. These reports typically list balances by 30, 60, 90, and 120 day increments.

Ancillary Services – These are typically services a patient requires in a hospital setting that are in addition to room and board accommodations – such as surgery, tests, counseling, therapy, etc.

Appeal – When an insurance plan does not pay for treatment, an appeal (either by the provider or patient) is the process of objecting this decision. The insurer may require documentation when processing an appeal and typically has a formal policy or process established for submitting an appeal. Many times the process and associated forms can be found on the insurance providers web site.

Applied to Deductible – You typically see these medical billing terms on the patient statement. This is the amount of the charges, determined by the patients insurance plan, the patient owes the provider. Many plans have a maximum annual deductible that once met is then covered by the insurance provider.

Assignment of Benefits – Insurance payments that are paid to the doctor or hospital for a patients treatment.

ASP – Application Service Provider. This is a computer based services over a network for a particular application. Sometimes referred to as SaaS (Software as a Service). There application service providers that offer Medical Billing. The appeal of an ASP is it frees a business of the the need to purchase, maintain, and backup software and servers.

Beneficiary – Person or persons covered by the health insurance plan.

Medical Billing Terms – Medical Billing Glossary

Blue Cross Blue Shield (BCBS) – An organization of affiliated insurance companies (approximately 450), independent of the association (and each other), that offer insurance plans within local regions under one or both of the association’s brands (Blue Cross or Blue Shield). Many local BCBS associations are non-profit BCBS sometimes acts as administrators of Medicare in many states or regions.

Capitation – A fixed payment paid per patient enrolled over a defined period of time, paid to a health plan or provider. This covers the costs associated with the patients health care services. This payment is not affected by the type or number of services provided.

CHAMPUS – Civilian Health and Medical Program of the Uniformed Services. Recently renamed TRICARE. This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors.

Charity Care – When medical care is provided at no cost or at reduced cost to a patient that cannot afford to pay.

Clean Claim – Medical billing term for a complete submitted insurance claim that has all the necessary correct information without any omissions or mistakes that allows it to be processed and paid promptly.

Clearinghouse – This is a service that transmits claims to insurance carriers. Prior to submitting claims the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as most errors can be easily corrected. Clearinghouses electronically transmit claim information that is compliant with the strict HIPPA standards (this is one of the medical billing terms we see a lot more of lately).

CMS – Centers for Medicaid and Medicare Services. Federal agency which administers Medicare, Medicaid, HIPPA, and other health programs. Formerly known as the HCFA (Health Care Financing Administration). You’ll notice that CMS it the source of a lot of medical billing terms.

CMS 1500 – Medical claim form established by CMS to submit paper claims to Medicare and Medicaid. Most commercial insurance carriers also require paper claims be submitted on CMS-1500’s. The form is distinguished by it’s red ink.

CodingMedical Billing Coding involves taking the doctors notes from a patient visit and translating them into the proper ICD-9 code for diagnosis and CPT codes for treatment.

COBRA Insurance – This is health insurance coverage available to an individual and their dependents after becoming unemployed – either voluntary or involuntary termination of employment for reasons other than gross misconduct. Because it does not typically receive company matching, It’s typically more expensive than insurance the cost when employed but does benefit from the savings of being part of a group plan. Employers must extend COBRA coverage to employees dismissed for a. COBRA stands for Consolidated Omnibus Budget Reconciliation Act which was passed by Congress in 1986.

COBRA coverage typically lasts up to 18 months after becoming unemployed and under certain conditions extend up to 36 months.

Co-Insurance – Percentage or amount defined in the insurance plan for which the patient is responsible. Most plans have a ratio of 90/10 or 80/20, 70/30, etc. For example the insurance carrier pays 80% and the patient pays 20%.

Collection Ratio – This is in reference to the providers accounts receivable. It’s the ratio of the payments received to the total amount of money owed on the providers accounts.

Contractual Adjustment – The amount of charges a provider or hospital agrees to write off and not charge the patient per the contract terms with the insurance company.

Coordination of Benefits – When a patient is covered by more than one insurance plan. One insurance carrier is designated as the primary carrier and the other as secondary.

Co-Pay – Amount paid by patient at each visit as defined by the insured plan.

CPT Code – Current Procedural Terminology. This is a 5 digit code assigned for reporting a procedure performed by the physician. The CPT has a corresponding ICD-9 diagnosis code. Established by the American Medical Association. This is one of the medical billing terms we use a lot.

Credentialing – This is an application process for a provider to participate with an insurance carrier. Many carriers now request credentialing through CAQH. CAQH credentialing process is a universal system now accepted by insurance company networks.

Credit Balance – The balance thats shown in the “Balance” or “Amount Due” column of your account statement with a minus sign after the amount (for example $50-). It may also be shown in parenthesis; ($50). The provider may owe the patient a refund.

Crossover claim – When claim information is automatically sent from Medicare the secondary insurance such as Medicaid.

Date of Service (DOS) – Date that health care services were provided.

Day Sheet – Summary of daily patient treatments, charges, and payments received.

Deductible – amount patient must pay before insurance coverage begins. For example, a patient could have a $1000 deductible per year before their health insurance will begin paying. This could take several doctor’s visits or prescriptions to reach the deductible.

Demographics – Physical characteristics of a patient such as age, sex, address, etc. necessary for filing a claim.

DME – Durable Medical Equipment – Medical supplies such as wheelchairs, oxygen, catheter, glucose monitors, crutches, walkers, etc.

DOB – Abbreviation for Date of Birth

Downcoding – When the insurance company reduces the code (and corresponding amount) of a claim when there is no documentation to support the level of service submitted by the provider. The insurers computer processing system converts the code submitted down to the closest code in use which usually reduces the payment.

Duplicate Coverage Inquiry (DCI) – Request by an insurance company or group medical plan by another insurance company or medical plan to determine if other coverage exists.

Dx – Abbreviation for diagnosis code (ICD-9 or ICD-10 code).

Electronic Claim – Claim information is sent electronically from the billing software to the clearinghouse or directly to the insurance carrier. The claim file must be in a standard electronic format as defined by the receiver.

Electronic Funds Transfer (EFT) – An electronic paperless means of transferring money. This allows funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.

E/M – Evaluation and Management section of the CPT codes. These are the CPT codes 99201 thru 99499 most used by physicians to access (or evaluate) a patients treatment needs.

EMR – Electronic Medical Records. This is a medical record in digital format of a patients hospital or provider treatment.

Enrollee – Individual covered by health insurance.

EOB – Explanation of Benefits. One of the medical billing terms for the statement that comes with the insurance company payment to the provider explaining payment details, covered charges, write offs, and patient responsibilities and deductibles.

ERA – Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.

ERISA – Employee Retirement Income Security Act of 1974. This law established the reporting, disclosure of grievances, and appeals requirements and financial standards for group life and health. Self-insured plans are regulated by this law.

Financial Responsibility – The portion of the charges that are the responsibility of the patient or insured.

Fiscal Intermediary (FI) – A Medicare representative who processes Medicare claims.

Formulary – A list of prescription drug costs which an insurance company will provide reimbursement for.

Fraud – When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

GPH – Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).

Medical Billing Glossary

Group Name – Name of the group or insurance plan that insures the patient.

Group Number – Number assigned by insurance company to identify the group under which a patient is insured.

Guarantor – A responsible party and/or insured party who is not a patient.

HCFA – Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

HCPCS – Health Care Financing Administration Common Procedure Coding System. (pronounced “hick-picks”). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a procedure code in the medical billing glossary.

The three HCPCS levels are:

  • Level I – American Medical Associations Current Procedural Terminology (CPT) codes.
  • Level II – The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures.
  • Level III – Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.

Healthcare Insurance – Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family policy which covers the beneficiary’s family members. May include coverage for disability or accidental death or dismemberment.

Medical Billing Glossary

Heathcare Provider – Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

Health Care Reform Act – Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.

HIC – Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

HIPAA – Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care. HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.

HMO – Health Maintenance Organization. A type of health care plan that places restrictions on treatments.

Hospice – Inpatient, outpatient, or home healthcare for terminally ill patients.

ICD-9 Code – Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.

ICD 10 Code – 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10.

Incremental Nursing Charge – Charges for hospital nursing services in addition to basic room and board.

Indemnity – Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital

In-Network (or Participating) – An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

Inpatient – Hospital stay of more than one day (24 hours).

IPA – Independent Practice Association. An organization of physicians that are contracted with a HMO plan.

Intensive Care – Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.

Financial Responsibility – The portion of the charges that are the responsibility of the patient or insured.

Fiscal Intermediary (FI) – A Medicare representative who processes Medicare claims.

Formulary – A list of prescription drug costs which an insurance company will provide reimbursement for.

Fraud – When a provider receives payment or a patient obtains services by deliberate, dishonest, or misleading means.

GPH – Group Health Plan. A means for one or more employer who provide health benefits or medical care for their employees (or former employees).

Medical Billing Glossary

Group Name – Name of the group or insurance plan that insures the patient.

Group Number – Number assigned by insurance company to identify the group under which a patient is insured.

Guarantor – A responsible party and/or insured party who is not a patient.

HCFA – Health Care Financing Administration. Now know as CMS (see above in Medical Billing Terms).

HCPCS – Health Care Financing Administration Common Procedure Coding System. (pronounced “hick-picks”). Three level system of codes. CPT is Level I. A standardized medical coding system used to describe specific items or services provided when delivering health services. May also be referred to as a procedure code in the medical billing glossary.

The three HCPCS levels are:

  • Level I – American Medical Associations Current Procedural Terminology (CPT) codes.
  • Level II – The alphanumeric codes which include mostly non-physician items or services such as medical supplies, ambulatory services, prosthesis, etc. These are items and services not covered by CPT (Level I) procedures.
  • Level III – Local codes used by state Medicaid organizations, Medicare contractors, and private insurers for specific areas or programs.

Healthcare Insurance – Insurance coverage to cover the cost of medical care necessary as a result of illness or injury. May be an individual policy or family policy which covers the beneficiary’s family members. May include coverage for disability or accidental death or dismemberment.

Medical Billing Glossary

Heathcare Provider – Typically a physician, hospital, nursing facility, or laboratory that provides medical care services. Not to be confused with insurance providers or the organization that provides insurance coverage.

Health Care Reform Act – Health care legislation championed by President Obama in 2010 to provide improved individual health care insurance or national health care insurance for Americans. Also referred to as the Health Care Reform Bill or the Obama Health Care Plan.

HIC – Health Insurance Claim. This is a number assigned by the the Social Security Administration to a person to identify them as a Medicare beneficiary. This unique number is used when processing Medicare claims.

HIPAA – Health Insurance Portability and Accountability Act. Several federal regulations intended to improve the efficiency and effectiveness of health care. HIPAA has introduced a lot of new medical billing terms into our vocabulary lately.

HMO – Health Maintenance Organization. A type of health care plan that places restrictions on treatments.

Hospice – Inpatient, outpatient, or home healthcare for terminally ill patients.

ICD-9 Code – Also know as ICD-9-CM. International Classification of Diseases classification system used to assign codes to patient diagnosis. This is a 3 to 5 digit number.

ICD 10 Code – 10th revision of the International Classification of Diseases. Uses 3 to 7 digit. Includes additional digits to allow more available codes. The U.S. Department of Health and Human Services has set an implementation deadline of October, 2013 for ICD-10.

Incremental Nursing Charge – Charges for hospital nursing services in addition to basic room and board.

Indemnity – Also referred to as fee-for-service. This is a type of commercial insurance were the patient can use any provider or hospital

In-Network (or Participating) – An insurance plan in which a provider signs a contract to participate in. The provider agrees to accept a discounted rate for procedures.

Inpatient – Hospital stay of more than one day (24 hours).

IPA – Independent Practice Association. An organization of physicians that are contracted with a HMO plan.

Intensive Care – Hospital care unit providing care for patients who need more than the typical general medical or surgical area of the hospital can provide. May be extremely ill or seriously injured and require closer observation and/or frequent medical attention.

The maximum amount the insured is responsible for paying for eligible health plan expenses. When this maximum limit is reached, the insurance typically then pays 100% of eligible expenses.

Medical Assistant – A health care worker who performs administrative and clinical duties in support of a licensed health care provider such as a physician, physicians assistant, nurse, nurse practitioner, etc.

Medical Coder – Analyzes patient charts and assigns the appropriate code. These codes are derived from ICD-9 codes (soon to be ICD-10) and corresponding CPT treatment codes and any related CPT modifiers.

Medical Billing Specialist – Processes insurance claims for payment of services performed by a physician or other health care provider. Ensures patient medical billing codes, diagnosis, and insurance information are entered correctly and submitted to insurance payer. Enters insurance payment information and processes patient statements and payments. Performs tasks vital to the financial operation of a practice. Knowledgeable in medical billing terminology.

Medical Necessity – Medical service or procedure that is performed on for treatment of an illness or injury that is not considered investigational, cosmetic, or experimental.

Medical Record Number – A unique number assigned by the provider or health care facility to identify the patient medical record.

MSP – Medicare Secondary Payer.

Medical Savings Account – Tax exempt account for paying medical expenses administered by a third party to reimburse a patient for eligible health care expenses. Typically provided by employer where the employee contributes regularly to the account before taxes and submits claims or receipts for reimbursement. Sometimes also referred to in medical billing terminology as a Medical Spending Account.

Medical Transcription – The conversion of voice recorded or hand written medical information dictated by health care professionals (such as physicians) into text format records. These records can be either electronic or paper.

Medicare – Insurance provided by federal government for people over 65 or people under 65 with certain restrictions. There are 2 parts:

Medicare Coinsurance Days – Medical billing terminology for inpatient hospital coverage from day 61 to day 90 of a continuous hospitalization. The patient is responsible for paying for part of the costs during those days. After the 90th day, the patient enters “Lifetime Reserve Days.”

Medicare Donut Hole – The gap or difference between the initial limits of insurance and the catastrophic Medicare Part D coverage limits for prescription drugs.

Medical Billing Terminology

Medicaid – Insurance coverage for low income patients. Funded by Federal and state government and administered by states.

MedigapMedicare supplemental health insurance for Medicare beneficiaries which may include payment of Medicare deductibles, co-insurance and balance bills, or other services not covered by Medicare.

Modifier – Modifier to a CPT treatment code that provide additional information to insurance payers for procedures or services that have been altered or “modified” in some way. Modifiers are important to explain additional procedures and obtain reimbursement for them.

N/C – Non-Covered Charge. A procedure not covered by the patients health insurance plan.

NEC – Not Elsewhere Classifiable. Medical billing terminology used in ICD when information needed to code the term in a more specific category is not available.

Network Provider – Health care provider who is contracted with an insurance provider to provide care at a negotiated cost.

Nonparticipation – When a healthcare provider chooses not to accept Medicare-approved payment amounts as payment in full.

NOS – Not Otherwise Specified. Used in ICD for unspecified diagnosis.

NPI Number – National Provider Identifier. A unique 10 digit identification number required by HIPAA and assigned through theNational Plan and Provider Enumeration System (NPPES).

OIG – Office of Inspector General – Part of department of Health and Human Services. Establish compliance requirements to combat healthcare fraud and abuse. Has guidelines for billing services and individual and small group physician practices.

Out-of Network (or Non-Participating) – A provider that does not have a contract with the insurance carrier. Patients usually responsible for a greater portion of the charges or may have to pay all the charges for using an out-of network provider.

Out-Of-Pocket Maximum – The maximum amount the patient has to pay under their insurance policy. Anything above this limit is the insurers obligation. These Out-of-pocket maximums can apply to all coverage or to a specific benefit category such as prescriptions.

Outpatient – Typically treatment in a physicians office, clinic, or day surgery facility lasting less than one day.

Palmetto GBA – An administrator of Medicare health insurance for the Centers for Medicare & Medicaid Services (CMS) in the US and its territories. A wholly owned subsidiary of BlueCross BlueShield of South Carolina based in Columbia, South Carolina.

Patient Responsibility – The amount a patient is responsible for paying that is not covered by the insurance plan.

PCP – Primary Care Physician – Usually the physician who provides initial care and coordinates additional care if necessary.

POS – Point-of-Service plan. Medical billing terminology for a flexible type of HMO (Health Maintenance Organization) plan where patients have the freedom to use (or self-refer to) non-HMO network providers. When a non-HMO specialist is seen without referral from the Primary Care Physician (self-referral), they have to pay a higher deductible and a percentage of the coinsurance.

POS (Used on Claims) – Place of Service. Medical billing terminology used on medical insurance claims – such as the CMS 1500 block 24B. A two digit code which defines where the procedure was performed. For example 11 is for the doctors office, 12 is for home, 21 is for inpatient hospital, etc.

PPO – Preferred Provider Organization. Commercial insurance plan where the patient can use any doctor or hospital within the network. Similar to an HMO.

Practice Management Software – software used for the daily operations of a providers office. Typically used for appointment scheduling and billing.

Preauthorization – Requirement of insurance plan for primary care doctor to notify the patient insurance carrier of certain medical procedures (such as outpatient surgery) for those procedures to be considered a covered expense.

Pre-Certification – Sometimes required by the patients insurance company to determine medical necessity for the services proposed or rendered. This doesn’t guarantee the benefits will be paid.

Predetermination – Maximum payment insurance will pay towards surgery, consultation, or other medical care – determined before treatment.

Pre-existing Condition (PEC) – A medical condition that has been diagnosed or treated within a certain specified period of time just before the patients effective date of coverage. A Pre-existing condition may not be covered for a determined amount of time as defined in the insurance terms of coverage (typically 6 to 12 months).

Pre-existing Condition Exclusion – When insurance coverage is denied for the insured when a pre-existing medical condition existed when the health plan coverage became effective.

Premium – The amount the insured or their employer pays (usually monthly) to the health insurance company for coverage.

Privacy Rule – The HIPAA privacy standard establishes requirements for disclosing what the HIPAA privacy law calls Protected Health Information (PHI). PHI is any information on a patient about the status of their health, treatment, or payments.

Provider – Physician or medical care facility (hospital) who provides health care services.

PTAN – Provider Transaction Access Number. Also known as the legacy Medicare number.

Referral – When one provider (usually a family doctor) refers a patient to another provider (typically a specialist).

Remittance Advice (R/A) – A document supplied by the insurance payer with information on claims submitted for payment. Contains explanations for rejected or denied claims. Also referred to as an EOB (Explanation of Benefits).

Responsible Party – The person responsible for paying a patients medical bill. Also referred to as the guarantor.

Secondary Insurance Claim – claim for insurance coverage paid after the primary insurance makes payment. Secondary insurance is typically used to cover gaps in insurance coverage.

Secondary Procedure – When a second CPT procedure is performed during the same physician visit as the primary procedure.

Security Standard – Provides guidance for developing and implementing policies and procedures to guard and mitigate compromises to security. The HIPAA security standard is kind of a sub-set or compliment to the HIPAA privacy standard. Where the HIPAA policy privacy requirements apply to all patient Protected Health Information (PHI), HIPAA policy security laws apply more specifically to electronic PHI.

Skilled Nursing Facility – A nursing home or facility for convalescence. Provides a high level of specialized care for long-term or acutely ill patients. A Skilled Nursing Facility is an alternative to an extended hospital stay or home nursing care.

SOF – Signature on File.

Software As A Service (SAAS) – One of the medical billing terms for a software application that is hosted on a server and accessible over the Internet. SAAS relieves the user of software maintenance and support and the need to install and run an application on an individual local PC or server. Many medical billing applications are available as SAAS.

Specialist – Pphysician who specializes in a specific area of medicine, such as urology, cardiology, orthopedics, oncology, etc. Some heathcare plans require beneficiaries to obtain a referral from their primary care doctor before making an appointment to see a Specialist.

Glossary of Billing Terms

Subscriber – Medical billing term to describe the employee for group policies. For individual policies the subscriber describes the policyholder.

Superbill – One of the medical billing terms for the form the provider uses to document the treatment and diagnosis for a patient visit. Typically includes several commonly used ICD-9 diagnosis and CPT procedural codes. One of the most frequently used medical billing terms.

Supplemental Insurance – Additional insurance policy that covers claims fro deductibles and coinsurance. Frequently used to cover these expenses not covered by Medicare.

TAR – Treatment Authorization Request. An authorization number given by insurance companies prior to treatment in order to receive payment for services rendered.

Taxonomy Code – Specialty standard codes used to indicate a providers specialty sometimes required to process a claim.

Term Date – Date the insurance contract expired or the date a subscriber or dependent ceases to be eligible.

Tertiary Insurance Claim – Claim for insurance coverage paid in addition to primary and secondary insurance. Tertiary insurance covers gaps in coverage the primary and secondary insurance may not cover.

Third Party Administrator (TPA) – An independent corporate entity or person (third party) who administers group benefits, claims and administration for a self-insured company or group.

TIN – Tax Identification Number. Also known as Employer Identification Number (EIN).

TOP – Triple Option Plan. An insurance plan which offers the enrolled a choice of a more traditional plan, an HMO, or a PPO. This is also commonly referred to as a cafeteria plan.

TOS – Type of Service. Description of the category of service performed.

TRICARE – This is federal health insurance for active duty military, National Guard and Reserve, retirees, their families, and survivors. Formerly know as CHAMPUS.

UB04 – Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500. Replaces the UB92 form.

Glossary of Billing Terms

Unbundling – Submitting several CPT treatment codes when only one code is necessary.

Untimely Submission – Medical claim submitted after the time frame allowed by the insurance payer. Claims submitted after this date are denied.

Upcoding – An illegal practice of assigning an ICD-9 diagnosis code that does not agree with the patient records for the purpose of increasing the reimbursement from the insurance payor.

UPIN – Unique Physician Identification Number. 6 digit physician identification number created by CMS. Discontinued in 2007 and replaced by NPI number.

Usual Customary & Reasonable(UCR) – The allowable coverage limits (fee schedule) determined by the patients insurance company to limit the maximum amount they will pay for a given service or item as defined in the contract with the patient.

Utilization Limit – The limits that Medicare sets on how many times certain services can be provided within a year. The patients claim can be denied if the services exceed this limit.

Utilization Review (UR) – Review or audit conducted to reduce unnecessary inpatient or outpatient medical services or procedures.

V-Codes – ICD-9-CM coding classification to identify health care for reasons other than injury or illness.

Workers Comp – Insurance claim that results from a work related injury or illness.

Write-off – Typically reference to the difference between what the physician charges and what the insurance plan contractually allows and the patient is not responsible for. May also be referred to as “not covered” in some glossary of billing terms.

What is  Modifier?

Definitions:

Modifiers provide the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by special circumstance but not changed in its definition or code.

Procedures and Responsibilities

Modifiers may be used to indicate to the recipient of a report that:

  • A service or procedure has both a technical and professional component.
  • A service or procedure was performed by more than one physician and/or in more than one location.
  • A service or procedure has been increased or decreased.
  • Only part of a service was performed.
  • An adjunctive service or procedure was performed.
  • A bilateral procedure was performed.
  • A service or procedure was performed more than once.
  • Unusual events occurred.

Oxford recognizes certain modifiers as outlined in the table below.

Modifier Description Recognized by Oxford? Additional Information
22 Increased procedural services Yes Refer to policy: Unusual Services
23 Unusual anesthesia No N/A
24 Unrelated evaluation and management service by the same physician during a postoperative period Yes Refer to policy: Global Surgical Package.
25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Yes N/A
26 Professional component Yes Refer to policy: Technical Component and Professional Component (TC/PC)
32 Mandated services No N/A
47 Anesthesia by surgeon Yes Dentists who are certified to administer in-office anesthesia only.
50 Bilateral procedure Yes Refer to policy: Bilateral Surgery
51 Multiple procedures Yes Refer to policy: Multiple Procedures Policy
52 Reduced services Yes Refer to policy: Reduced Services
53 Discontinued procedure No N/A
54 Surgical care only Yes Refer to policy: Modifiers 54, 55, 56
55 Postoperative management only Yes Refer to policy: Modifiers 54, 55, 56
56 Preoperative management only Yes Refer to policy: Modifiers 54, 55, 56
57 Decision for surgery Yes Refer to policy: Global Surgical Package
58 Staged or related procedure or service by the same physician during the postoperative period Yes Refer to policy: Global Surgical Package
59 Distinct procedural service Yes N/A
62 Two surgeons Yes Refer to policy: Co-Surgeons; Team Surgery
63 Procedure performed on infants less than 4 kg Yes Refer to policy: Unusual Services
66 Surgical team Yes Refer to policy: Co-Surgeons; Team Surgery
76 Repeat procedure or service by same physician Yes Refer to policy: Same Day/Same Service
77 Repeat procedure by another physician Yes Refer to policy: Same Day/Same Service
78 Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period No N/A
79 Unrelated procedure or service by the same physician during the postoperative period No N/A
80 Assistant surgeon Yes Refer to policy: Assistants at Surgery
81 Minimum assistant surgeon Yes Refer to policy: Assistants at Surgery
82 Assistant surgeon (when qualified resident surgeon not available) Yes Refer to policy: Assistants at Surgery
90 Reference (outside) laboratory No N/A
91 Repeat clinical diagnostic laboratory test No N/A
92 Alternative laboratory platform testing No N/A
99 Multiple modifiers No N/A
A1 Dressing for one wound Yes Informational purposes only.
A2 Dressing for two wounds Yes Informational purposes only.
A3 Dressing for three wounds Yes Informational purposes only.
A4 Dressing for four wounds Yes Informational purposes only.
A5 Dressing for five wounds Yes Informational purposes only.
A6 Dressing for six wounds Yes Informational purposes only.
A7 Dressing for seven wounds Yes Informational purposes only.
A8 Dressing for eight wounds Yes Informational purposes only.
A9 Dressing for nine or more wounds Yes Informational purposes only.
AA Anesthesia services performed personally by anesthesiologist Yes Reimbursement allowed at 100% of the UCR or fee schedule.
AE Registered dietician Yes Informational purposes only.
AF Specialty physician Yes Informational purposes only.
AG Primary physician Yes Informational purposes only.
AH Clinical psychologist Yes Informational purposes only.
AI Principal physician of record Yes Informational purposes only.
AJ Clinical social worker Yes Informational purposes only.
AK Nonparticipating physician Yes Informational purposes only.
AM Physician, team member service Yes Informational purposes only.
AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination Yes Informational purposes only.
AQ Physician providing a service in an unlisted health professional shortage area (HPSA) Yes Informational purposes only.
AR Physician scarcity area Yes Informational purposes only.
AS PA, nurse practitioner, or clinical nurse specialist services for assistant at surgery Yes Refer to policy: Assistants at Surgery
AT Acute treatment Yes Informational purposes only.
AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
AW Item furnished in conjunction with a surgical dressing Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
AX Item furnished in conjunction with dialysis services Yes Informational purposes only.
BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
BL Special acquisition of blood and blood products Yes Informational purposes only.
BO Orally administered nutrition, not by feeding tube Yes Informational purposes only.
CR Catastrophe/disaster related Yes Informational purposes only.
E1 Upper left, eyelid Yes Informational purposes only.
E2 Lower left, eyelid Yes Informational purposes only.
E3 Upper right, eyelid Yes Informational purposes only.
E4 Lower right, eyelid Yes Informational purposes only.
ET Emergency services Yes Informational purposes only.
F1 Left hand, second digit Yes Informational purposes only.
F2 Left hand, third digit Yes Informational purposes only.
F3 Left hand, fourth digit Yes Informational purposes only.
F4 Left hand, fifth digit Yes Informational purposes only.
F5 Right hand, thumb Yes Informational purposes only.
F6 Right hand, second digit Yes Informational purposes only.
F7 Right hand, third digit Yes Informational purposes only.
F8 Right hand, fourth digit Yes Informational purposes only.
F9 Right hand, fifth digit Yes Informational purposes only.
FA Left hand, thumb Yes Informational purposes only.
FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples) No N/A
FC Partial credit received for replaced device No N/A
G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening Yes Refer to policy: Abortions for Medicare Plans
GG Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day Yes Informational purposes only.
GH Diagnostic mammogram converted from screening mammogram on same day Yes Informational purposes only.
GM Multiple patients on one ambulance trip Yes Informational purposes only.
GQ Via asynchronous telecommunications system Yes Refer to policy: Telemedicine
GR This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, supervised in accordance with VA policy Yes Informational purposes only.
GS Dosage of EPO or darbepoetin alfa has been reduced and maintained in response to hematocrit or hemoglobin level Yes Informational purposes only.
GT Via interactive audio and video telecommunication systems Yes Refer to policy: Telemedicine
GW Service not related to the hospice patient’s terminal condition Yes Informational purposes only.
H9 Court-ordered Yes Informational purposes only.
HA Child/adolescent program Yes Informational purposes only.
HB Adult program, nongeriatric Yes Informational purposes only.
HC Adult program, geriatric Yes Informational purposes only.
HD Pregnant/parenting women’s program Yes Informational purposes only.
HE Mental health program Yes Informational purposes only.
HF Substance abuse program Yes Informational purposes only.
HG Opoid addiction treatment program Yes Informational purposes only.
HH Integrated mental health substance abuse program Yes Informational purposes only.
HI Integrated mental health and mental retardation/developmental disabilities program Yes Informational purposes only.
HJ Employee assistance program Yes Informational purposes only.
HK Specialized mental health programs for high-risk populations Yes Informational purposes only.
HL Intern Yes Informational purposes only.
HM Less than bachelor degree level Yes Informational purposes only.
HN Bachelors degree level Yes Informational purposes only.
HO Masters degree level Yes Informational purposes only.
HP Doctoral level Yes Informational purposes only.
HQ Group setting Yes Informational purposes only.
HR Family/couple with client present Yes Informational purposes only.
HS Family/couple without client present Yes Informational purposes only.
HT Multi-disciplinary team Yes Informational purposes only.
J1 Competitive acquisition program (CAP) no-pay submission for a prescription number Yes Informational purposes only.
J2 Competitive acquisition program (CAP), restocking of emergency drugs after emergency administration Yes Informational purposes only.
J3 Competitive acquisition program (CAP), drug not available through CAP as written, reimbursed under average sales price methodology Yes Informational purposes only.
J4 DMEPOS item subject to DMEPOS competitive bidding program that is furnished by a hospital upon discharge Yes Informational purposes only.
JA Administered intravenously Yes Informational purposes only.
JB Administered subcutaneously Yes Informational purposes only.
JC Skin substitute used as graft Yes Informational purposes only.
JD Skin substitute not used as graft Yes Informational purposes only.
K0 Lower extremity prosthesis functional level 0 Yes Informational purposes only.
K1 Lower extremity prosthesis functional level 1 Yes Informational purposes only.
K2 Lower extremity prosthesis functional level 2 Yes Informational purposes only.
K3 Lower extremity prosthesis functional level 3 Yes Informational purposes only.
K4 Lower extremity prosthesis functional level 4 Yes Informational purposes only.
KA Add on option/accessory for wheelchair Yes Informational purposes only.
KB Beneficiary requested upgrade for ABN, more than four modifiers identified on claim Yes Informational purposes only.
KC Replacement of special power wheelchair interface Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
KD Drug or biological infused through DME Yes Informational purposes only.
KF Item designated by FDA as class III device Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
KL DMEPOS item delivered via mail Yes Informational purposes only.
KM Replacement of facial prosthesis including new impression/moulage Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
KN Replacement of facial prosthesis using previous master model Yes Use of this modifier may impact reimbursement for certain HCPCS codes. Refer to the applicable vendor contract and/or DMEPOS fee schedule for additional information.
KO Single drug unit dose formulation Yes Informational purposes only.
KP First drug of a multiple drug unit dose formulation Yes Informational purposes only.
KQ Second or subsequent drug of a multiple drug unit dose formulation Yes Informational purposes only.
LC Left circumflex coronary artery Yes Informational purposes only.
LD Left anterior descending coronary artery Yes Informational purposes only.
LL Lease/rental (use the LL modifier when DME equipment rental is to be applied against the purchase price) No N/A
LR Laboratory round trip Yes Informational purposes only.
LS FDA-monitored intraocular lens implant Yes Informational purposes only.
LT Left side (used to identify procedures performed on the left side of the body) Yes Informational purposes only.
MS Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty Yes Refer to policy: Durable Medical Equipment
NR New when rented No N/A
NU New equipment Yes Refer to policy: Durable Medical Equipment
P1 A normal healthy patient Yes Anesthesia physical status modifier.
P2 A patient with mild systemic disease Yes Anesthesia physical status modifier.
P3 A patient with severe systemic disease Yes Anesthesia physical status modifier.
P4 A patient with severe systemic disease that is a constant threat to life Yes Anesthesia physical status modifier.
P5 A moribund patient who is not expected to survive without the operation Yes Anesthesia physical status modifier.
P6 A declared brain-dead patient whose organs are being removed for donor purposes Yes Anesthesia physical status modifier.
Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study Yes Informational purposes only.
Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study Yes Informational purposes only.
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals Yes Reimbursement allowed at 50% of the UCR or fee schedule.
QM Ambulance service provided under arrangement by a provider of services Yes Informational purposes only.
QN Ambulance service furnished directly by a provider of services Yes Informational purposes only.
QS Monitored anesthesia care service Yes Informational purposes only.
QX CRNA service: with medical direction by a physician Yes Reimbursement allowed at 50% of the UCR or fee schedule.**Refer to policy: Physician Extenders
QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist Yes Reimbursement allowed at 50% of the UCR or fee schedule.**Refer to policy: Physician Extenders
QZ CRNA service: without medical direction by a physician Yes Reimbursement allowed at 100% of the UCR or fee schedule.
RA Replacement of a DME item Yes Informational purposes only.
RB Replacement of a part of DME furnished as part of a repair Yes Informational purposes only.
RC Right coronary artery Yes Informational purposes only.
RE Furnished in full compliance with FDA-mandated risk evaluation and mitigation Yes Informational purposes only.
RP Replacement and repair No N/A
RR Rental (use the RR modifier when DME is to be rented) Yes Refer to policy: Durable Medical Equipment
RT Right side (used to identify procedures performed on the right side of the body) Yes Informational purposes only.
SA Nurse practitioner rendering service in collaboration with a physician Yes Informational purposes only.
SB Nurse midwife Yes Refer to policy: Physician Extenders
SC Medically necessary service or supply No N/A
SD Services provided by registered nurse with specialized, highly technical home infusion training Yes Informational purposes only.
SG Ambulatory surgical center (ASC) facility service Yes Informational purposes only.
SM Second surgical opinion Yes Informational purposes only.
SN Third surgical opinion Yes Informational purposes only.
SQ Item ordered by home health Yes Informational purposes only.
ST Related to trauma or injury Yes Informational purposes only.
SU Procedure performed in physician’s office (to denote use of facility and equipment) Yes This modifier applies only to participating providers with specific mention of OFAC and/or modifier -SU in their contract.
T1 Left foot, second digit Yes Informational purposes only.
T2 Left foot, third digit Yes Informational purposes only.
T3 Left foot, fourth digit Yes Informational purposes only.
T4 Left foot, fifth digit Yes Informational purposes only.
T5 Right foot, great toe Yes Informational purposes only.
T6 Right foot, second digit Yes Informational purposes only.
T7 Right foot, third digit Yes Informational purposes only.
T8 Right foot, fourth digit Yes Informational purposes only.
T9 Right foot, fifth digit Yes Informational purposes only.
TA Left foot, great toe Yes Informational purposes only.
TC Technical component Yes Refer to policy: Technical Component and Professional Component (TC/PC)
TD RN Yes Refer to policy: Home Health Care for Commercial
TE LPN/LVN Yes Refer to policy: Home Health Care for Commercial
TL Early intervention/individualized family service plan (IFSP) Yes Refer to policy: Early Intervention Program / Birth to Three
TS Follow-up service Yes Informational purposes only.
TW Back-up equipment No N/A
UE Used durable medical equipment Yes Refer to policy: Durable Medical Equipment
UF Services provided in the morning Yes Informational purposes only.
UG Services provided in the afternoon Yes Informational purposes only.
UH Services provided in the evening Yes Informational purposes only.
UJ Services provided at night Yes Informational purposes only.
V5 Vascular catheter Yes Informational purposes only.
V6 Arteriovenous graft Yes Informational purposes only.
V7 Arteriovenous fistula Yes Informational purposes only.
V8 Infection present Yes Informational purposes only.
V9 No infection present Yes Informational purposes only.

 

What is procedure code?

Procedure codes are numbers or alphanumeric codes used to identify specific health interventions taken by medical professionals

Cpt codes

99213 is for Established patient office or other outpatient services

                 Denial Management

Billing Specialists at Finch fully understand the complexities involved in dealing with Insurance companies and Denial Management is our specialty. Finch Targets A/R ratios as follows.

  • 61-90 days : 5-10%
  • 91-120 days : 2-5%
  • Above 120 days : 0-2%

Our team will review all unpaid claims within 15–30 days of initial billing date and take the required action to make sure you get paid for each claim. All denials are appealed in a timely manner. And when a Claim needs Medical Necessity notes, Pre Existing information, Place of service or type of service etc., these notes will be collected from the client’s end, analyzed and submitted to the payers.

                                               Medical Billing

Finch’s Medical Billing service will help you focus on your practice and takes the headache out of billing and claims process. Medical Billing is Finch Healthcare’s core competency and clients have realized fewer denials and improved re-imbursements by switching to our service. Our billing solutions are designed to reduce or eliminate most of the overhead associated with billing and claims, thereby reducing the work load on your office staff and helps you stay focused on patient care.

While Finch offers end-to-end billing solutions including A/R management, our billing services can also be customized to include one or more of the following.

  • Patient Demographic Entry and Insurance Precertification
  • Medical Coding (CPT and ICD 9)
  • Charge Entry Electronic Claim Submission
  • Payment Posting
  • A / R follow up and Denial Management
  • What is Benefit exhausted?

This denial actually mean current insurance has already enough paid for this patient hence this insurance cant pay more. Patient coverage is active but insurance will not pay since the amount of maximum payable has been reached . Bill the patient for allowed amount.

Following are many reports that Finch offers to help you understand the process better and keep tab on the
billing activities.

  • Daily activity reports
  • Monthly activity report
  • Charges and payment analysis
  • Insurance distribution analysis
  • Payment and adjustments analysis
  • Aging reports
  • Denial analysis
  • Evaluation and Management auditing report
  • Procedure code analysis
  • And customized reports

Process Flow

  Creteria Of Insurance

Medicare Eligibility : The Centers for Medicare & Medicaid Services (CMS) administers Medicare, the nation’s largest health insurance program, which covers nearly 40 million Americans. Medicare is a Health Insurance Program for people age 65 or older, some disabled people under age 65, and people of all ages with End-Stage Renal Disease (permanent kidney failure treated with dialysis or a transplant).

Medicaid

Medicaid is a health insurance program offered by the U.S. government that helps eligible low-income Americans pay for some or all of their medical costs. Low income is only one factor in determining Medicaid eligibility. Other factors affecting eligibility include the applicant’s age, pregnancy, disability, blindness and U.S. citizenship status.

1.   Mandatory Eligibility

The federal government requires that certain groups be eligible for Medicaid in order for the states to obtain Medicaid funding. For example, SSI (Supplemental Security Income) recipients and children born to Medicaid-eligible pregnant women, as well as certain Medicare recipients, are covered in this category.

Basic Eligibility Criteria

You may be eligible for Medicaid if your income is low and you match one of the following descriptions:

  • You think you are pregnant
  • You are a child or teenager
  • You are age 65 or older
  • You are legally blind
  • You have a disability
  • You need nursing home care

   

What is the difference between HMO & PPO?

A health maintenance organization (HMO) and a preferred provider organization (PPO) have several differences. However, many of them offer quite similar services. Often the PPO will cost a little more because it provides greater flexibility in choosing doctors and seeing specialists than does the HMO.

With a PPO, one can see any doctor one wishes, or visit any hospital one chooses, usually within a preferred network of providers. Depending upon the terms of coverage, a doctor or hospital outside the preferred provider list will cost more and the PPO will pay a range of 70-80% of expenses. Conversely, an HMO requires one see only doctors or hospitals on their list of providers.

A few exceptions exist. A large HMO like Kaiser Permanente may allow one to use hospitals or specialists that perform a service their contracted doctors and facilities don’t provide. Unless the health situation is an emergency, obtaining services like these usually involve approval processes and may require a great deal of paperwork and red tape.

Advantages of Hmo:

 

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