Medical billing is an allied service support department to healthcare providers for both hospital and doctors. As the expectations and standards for proper medical coding and medical billing procedures become more stringent, medical billing and coding evolved to be a separate small and large companies inevitably becoming an integral part of the health care industry. Medical billing is always filled with complex procedure and routine work of billing and collecting due re-imbursement from insurance carrier for medical and healthcare services provided to patients. Right medical billing requires not only a spectrum of knowledge and understanding of the medical billing process but also blended with provider specialty billing experience, and awareness of constantly changing health insurance company rules and norms.

Medical Billing – Patient Demographic Entry:

When a physician or healthcare provider renders medical services to a patient they are entitled for reimbursement. Collecting these due moneys from the insurance is the medical biller’s role. After each healthcare appointment the medical biller reviews the super bill or encounter forms attached to the patient’s record to establish which services were provided. Next they re-check the patient’s insurance coverage and note the name of the health insurance company. Then they prepare proper invoices and submit the claim to the insurance carrier.

Medical billing – Medical Coding

In this process text medical information from medical notes, super bills are converted into appropriated defined ICD and CPT codes acceptable by insurance carriers. Assigning of codes to diagnoses and procedures, which help in financial reimbursement from insurance companies and government agencies. Medical Coding enhance in identifying the claims and displays the entire patient history and the services performed by the healthcare provider. Medical Coders convert the physicians note into medical codes that is utilized by the insurance carriers in compensating the health care provider. All coding are done under full compliance with HIPAA and AMA guidelines.

Patient demographic entry:

In this is a process wherein patient demographic details are collected from the patient at the time of new patient visit. When a patient comes for the first time to a practice or hospital they have to fill a new patient registration form which consists of THREE major categorized details patients, guarantor, and insurance information. This would include Patient’s and guarantor’s Name, Present Address, City, State, Zip Code, Social Security Number, Employer Details, Insurance Details like Primary, Secondary and Tertiary, workman’s compensation and guarantor information

Without the said information we cannot create an account for the patient or able to submit any claims to the insurance carrier. It’s also important to create the patient account for any reminders of subsequent visit scheduling or collections.

Medical Billing – Claims Entry

Charge-entry is one of the main segment which holds integral part of Medical Billing. It is the keying-in department in Medical Billing. Once the super bills and encounter forms ( patient registration form/ doctor office notes/ prescription notes) are received from the Doctor’s office, it gets passed through first phase of billing were procedure codes, HCPCS, diagnosis codes, modifiers, place of service, type of service and units are extracted from the super bills by pre-coding and coding department. Then comes to the charge-entry department, were the captured codes are entered in the applicable fields and the claim is created. The charge-entry person creates an individual account for every patient demographics that comes for the first time, and also assigns individual account #for the same. A Charge-entry person also does the quality check on coding and brings to immediate attention of the supervisor for any up-coding or down coding done. This comes only by experience and knowledge in that doctor’s specialty billing. Once the claims entry are completed and merged with patient demo information, it is ready for auditing and gets transmitted to the insurance company electronically through clearing house.

Medical Billing – EDI rejections: once the claims are transmitted to the insurance company electronically through clearing house, we would get the acknowledgements from clearing house on transmission whether or not claims reached the payer side, this called EDI reports. All clearing house does the pre-scanning on data received for any errors or missed out information on claims. If there be any data entry errors clearing house would reject the claims as per their specifications. This EDI rejection report would state clearly the type of error and where it as occurred. Those claims come back to the charge entry department for re-work.

Medical Billing – Payment Posting and Adjustments.

Optimize reimbursements by manage your denials together with posting payments, BOSS’s payment posting solutions saves your office valuable time, improve data accuracy, and flow of money into the proper accounts. Posting of insurance payments is a time consuming process. When a practice receives payment and an EOB notice, the information must be posted into the appropriate accounts with codes and adjustments with proper tallying of check received and EOB. This will enable to judge proper revenue flow and aggressive AR management. Additional complications such as capitation insurance contracts, co-pay, deductibles, global payments, AR adjustment, refunds and secondary insurances can be easily handled.

Some practice will have multiple individuals and/or locations receiving payments. This necessitates maintaining multiple bank deposit slips, each requiring their own reconciliation and posting.

Once the scan files are received, the cash poster prepares

  • (A) Cash Control Log: This shows the scan file number, scan date, number of pages, deposit date, batch number, deposit amount, posted amount, un-posted amount, backlog, & remarks. This is maintained month wise for every year. These logs are prepared for internal use and are not required by the client
  • (B) Monthly Deposit Log: the client sends this once or twice in a week. This contains the deposit amounts by deposit date. During month end, this log is checked to ensure whether all cash is received and posted.

Medical Billing – Types of payment posting

  • Patient payments: Patient payments by the patient for the co-pays, co-insurance and deductibles which are determined by insurances carrier.
  • Collection Agency Payments: When the patients defers from making their payment for a long period of time, the accounts would be referred to a collection agency. The collection agency in turn, will take necessary steps to get the payments from such patients. These payments when received are marked as Collection payments.
  • Insurance payments: Posting payments received from insurance carrier to the respective open patient account, insurance allowed amount, paid amount, patient responsibility and contractual write off.
  • Denial posting: Denial positing is an integral part of payment posting, no EOB contains only payments it also consists of mixture denials. Posting denial and initiating corresponding action is a must in a medical billing cycle, this will reduce the account receivables days.

During the course of cash posting, we may encounter offsets, refunds, clarification from insurance etc.

Medical Billing – Refund is processed for the following reasons:

  • The insurance carrier or the patient has overpaid.
  • Two carriers paid the claim as primary.
  • Both the secondary insurance and the patient as paid co-insurance.
  • Stated charge/patient is not in the account

Medical Billing – Payment Adjustments

Non-collectable amounts are charge adjusted using specific transactions.

Small Balance Adjustment:
If any small amount is left out by the insurance or patient after making the payment, that can be adjusted as small balance adjustment. A small balance adjustment will be done on balances that are $10.00 or less or as per the client instructions.

Medical Billing – Filing Limit Adjustment:
If the insurance denies the claim as filing limit exceeded even after appeal or where the claim itself was indeed first filed after the filing limit, you have to take a filing limit adjustment.
1. Lack of office/Timely filing (due to delays in replies from the Dr’s office)
2. Lack of follow up (due to delays in appropriate follow up by staff or delays due to staff not responding)

Medical Billing – Deceased Adjustment:
If you have received information that a patient has deceased, either through call or through regular mail correspondence, you need to do a deceased adjustment. We need to make sure that patient has left no estate before closing.

Medical Billing – Bankruptcy Adjustment:
If a patient has filed bankruptcy, a bankruptcy adjustment will be done. If we receive a bankruptcy notification that a guarantor has filed and/or been approved (discharge of debt) from a US court and/or attorney’s office (Chapter 7, 11, or 13 respectively):

Medical Billing – Billing Error Adjustment:
If the charge is on account of a billing error, then a billing error adjustment is taken.

Medical Billing – Bundled Services Adjustment:
Bundled services are those for which the reimbursement is included in that of another procedure. If a procedure has been denied as a bundled code, then a bundled services adjustment is taken.

Medical Billing – Insurance follow-up

BOSS has contingency plans on claims follow-up.

  • BOSS follows up with all insurance claims after every 35days from date of claim submissions.
  • BOSS runs aging report breaking down by age of claims and by insurance carrier. Analyzing on non-payments and follow-up with insurance carrier and patient for resolving the claim.

How it works?

Clients can scan their patient registration form and super bills and upload to our secured FTP server. From our FTP server we down load to our working data server and move it to the appropriate work folder to be entered.

Our billing agents would enter the patient information and charges to the applicable fields in abide with any client specifications in the billing system after creating the patient account.

Once the batch is completed, we would send a report the client on the received patient demo batch and charges ented. Report will contain a detail on number of new patient, modified existing patient demo entered, dropped charges, information missing, scanned imaged not clear and re-scanning required.

Client will respond to the report sent making outsourcing a success.

Medical Billing – Quality Analysis: Accurate entry of charge information is critical for obtaining timely and accurate payment. Insurance companies will easily deny a reimbursement due to incorrect information. In fact, it is estimated that as many as 80 percent of rejected claims are due to clerical errors.

BOSS follows TWO TIRE quality check on all billing work.

Medical Billing – Level I- Floor QC: The entire demo and charge entered is quality checked by field by field for errors and checking for client specifications error by the floor QA team.

Medical Billing – Level II- Random QC: BOSS senior QC team who monitors entire operations randomly picks demo and charge entered by the each billing staffs every half hour and quality checks for error and reporting back to the account manager and billing staffs.

Medical Billing – Quality Control check points.

  • Check for typo error
  • Billing error
  • Specification error
  • System error

Weekly quality audit reports are submitted to each team, performance of each billing staffs are monitored and appraised periodically.

Medical Billing – Error level @ BOSS: BOSS has impeccable error record of 0.99, with combined knowledge of operation and QA team we have crossed mile stones in quality deliverables and satisfied clientele relation.