Medical Billing for Medical Assistant and Medical Assistants
Healthcare has become one of the fastest growing industries in the United States! Hospitals, private practices and clinics could not survive without someone who efficiently handles their day-to-day Medical Billing procedures. Medical Billing Specialists are responsible for accurately completing claim forms, promptly billing insurance companies, and adhering to each insurance carrier's policies and procedures. Often done by a medical assistant in the medical office. 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. The same process is used for most insurance companies, whether they are private companies or government-owned.
Medical Assistant :: Billing and Coding for the Medical Assistant :
The billing process is an interaction between the provider and the insurance company (payer). It begins with the office visit. After the provider sees the patient, depending on the service provided and the examination, the doctor creates or updates the patient's medical record. This record contains a summary of treatment and demographic information related to In order to be clear on the payment of a medical billing claim, the physician must have complete knowledge of different insurance plans that insurance companies are offering, and the laws & regulations that preside over them. Large insurance companies can have up to 15 different plans contracted with one physician. That is why the amount is settled between the physician and the company before he provides his services and is paid according to the each contract that has its own fee schedule, billing rules and billing address.
Based on the amount negotiated by the doctor and the insurance company, the original charge is reduced. The amount that is paid by the insurance is known as an allowable. For example, although a psychiatrist may charge $80.00 for a medication management session, the insurance may only allow $50.00, so a $30 reduction would be assessed or otherwise called provider write off. After payment has been made a patient will typically receive an Explanation of Benefits (EOB) that outlines these transactions.the patient. Upon the first visit, the provider will usually give the patient a diagnosis (or possibly several diagnoses), in order to better coordinate and streamline his/her care. The patient record contains personal information, nature of illness, diagnosis and suggested treatment as well. This whole process - the first visit - is called an ‘encounter’.
The treatment, diagnosis, and duration of service combine to determine the procedure code that will be used to bill the insurance. The doctor then either provides this information to a medical coder or other billing specialist. From this, a billing record, either paper (usually on a standardized form called an HCFA, named for the previous name for the Centers for Medicare and Medicaid Services) or electronic, is generated. This form includes the various diagnoses identified by numbers from the current ICD-10 manual.
This billing record or claim is then submitted either to a clearinghouse that acts as an intermediary for the information (this is typical for electronic billing) or directly to the insurance company. Some of the electronic transactions are sent via Electronic Data Interchange (EDI).
Choosing a clearinghouse is very cost effective for medical billing because they edit the claim based on the rules stated by the payer. If the claim does not meet necessary criteria, the claim is sent back to the user, so they can make corrections and quickly retransmit it. This saves time as well as later complications.
The insurance company (payer) processes the claim. The insurance side of the process begins with testing the validity of the claim for payment. The tests cover patient eligibility for payment, provider credentials, and medical necessity. Upon passing successfully the tests, the payer pays the claim. If a claim fails the tests, the payer rejects the claim and communicates the rejection message to the claim submission source.
Upon receiving the rejection message, the provider must decipher the message, reconcile it with the original claim, make required corrections, and resubmit the claim again. This exchange of claims and messages may repeat multiple times until the claim is paid in full.HIPAA is a set of rules and regulations which hospitals, doctors, healthcare providers and health plans must follow in order to provide their services aptly and that there is no breach of confidence while maintaining patient records.
Since 2005 medical providers have been urged to electronically send their claims in compliance with HIPAA to receive their payment.
Title I of this Act protects health insurance of workers and their families when they change or lose a job. While Title II calls for the electronic transmission of major financial and administrative dealings, including billing, electronic claims processing, as well as imbursement advice.
Medical billing service providers and insurance companies were not the only ones affected by HIPAA regulations - many patients found that their insurance companies and health care providers required additional waivers and paperwork related to HIPAA.
