Medical Insurance

Let’s take, for instance, health care service providers, those in a bid to save money try and do all possible tasks themselves, without even considering, whether they are fit to perform them or not. As a result, the tasks do not yield desired output. The solution to it is doing tasks that fit your skill set best then only the best of the results could be achieved.

Medical billing is one such service that helps medical practitioners, hospitals, health care service providers to achieve specialized and gainful results, without putting in too many overspecialized efforts. The above discussed entities often stay engrossed in serving the patients for utmost customer satisfaction. In such a case, they either would need to hire a team of expert professionals (who could process the medical billing for them to help recover their due payments from patients’ insurance companies on time, along with due follow-up), and bear their monthly compensation and maintenance cost or outsource their tedious task to an expert medical billing service provider. The latter is a more specialized, cost efficient and an effective option.

Health care service providers lose millions of dollars annually due to under pricing, coding errors, missed charges and un-reimbursed claims of their medical services. To avoid this, it is important that experts with latest technological and software knowledge provide customized solutions to meet individual clients specific requirements. All this could well be ensured by adept medical billing service.

It involves a lot of complexities but trained medical billing service providers ease and uncomplicated the process to help medical organizations recover their dues. Deft billed understand the basic and major medical coverage plans, such as the Health Maintenance Organizations (HMO), Fee-for-Service Plans, Preferred Provider Organizations, Point-of-Service Plans and know the different methods of billing patients and understand the medical billing industry and all its complexities.

The expert billers are also well versed with the terminology & soft wares most often used in a medical office like MediSoft, AdvantX, Surgi Source, etc. Besides they also hold expertise in electronically filing claims, and possess knowledge on the most common types of insurance policies. Billing experts are also well aware of spreadsheets, electronic mail, database management, and possess contemporary word processing skills, proficient in bookkeeping for the most flawless bill raising and hassle free recovery.

Nowadays, we all agree that finding a good job is very difficult. Although we are a fresh graduated from a university, we still find difficulty in getting a good job. We need to be smart and have enough skill so that we can be chosen the work in a very good company. Therefore, we should prepare it well before we enroll ourselves in a university. We should choose correct study program so that we will get good job later on.

If you want to work in the health care industry, you are in the right tract since working in health care industry is very promising. One job that you can do in health care industry is medical biller. You can join at a medical billing training program if you want to be a medical biller. Fortunately, many universities also provide that program for you. The training program will bring you to have a successful job in your future. If you can choose the best training, you will be guided by some professional medical billers that have a lot of experiences in guiding a training program. Of course it will be very useful for your future career if you want to be a medical biller.

If you can be a medical biller, you will get high salary. It is very interesting, right? Some medical billing training programs only have affordable fees but you will be able to work in the health care industry with high salary. If you are smart and want to work in the health care industry, joining at a medical billing training program will be the best decision for your future. So, what are you waiting for? I suggest you to go to the internet and search some institutions which provide medical billing training program for you. I am sure that you will have enough finance for your future. It will bring you to a happy family, then. Let’s try!

When starting a medical billing business there are many things to think about and writing a contract is just one of them. There are many expenses in getting started and most of us just starting out don’t want to spend our limited investment money on an attorney. So what do many of us do? We “google” sample medical billing contract and use what we think sounds good and make up a contract for our business. That can be a big mistake.

That’s what we did sixteen years ago when we started our business except there was no ‘”Google” then. But we basically searched until we found a sample, very simple contract and modified it for our use. For several years we told ourselves that it was fine and if it wasn’t working out for the provider then it wasn’t working for us either and we should move on and find new clients. It took us a long time to realize that in several situations our simple contract was actually the reason things were not working out.

When you first start your medical billing business you have no idea of the things that can go wrong in a relationship with your clients so you do not know what needs to be included in a contract. Our first contract did not even specify the responsibilities of either the provider or ourselves. It is amazing we were able to find providers willing to sign our contract. If you don’t include the responsibilities of each party in the contract how does it protect either of you when the relationship starts to fall apart? And if neither party knows their responsibilities, how can you expect that the relationship will work?

Here is an example. You specify in the contract that it is the obligation of the provider’s office representative to supply you with all the payment remittances but you are not getting them which is causing you to do a lot of extra work in contacting the insurance carriers to check status on claims that were already paid. It is upsetting to spend three or four hours calling insurance companies to find that the claims were paid but the doctor’s office missed sending you the eobs. When the doctor has signed a contract that says that he will designate a person responsible for that purpose you can nicely inform the person responsible for getting you the eobs that this is such an important issue to you that it is written into the contract that the doctor signed that you are to be provided with the eobs. You can also include a provision in the contract to specify what you can do if the provider is not providing you with the eobs.

Another important example is an issue you will undoubtedly run into – your payment. Many people who start this business are used to receiving a regular paycheck. When you make the move to being an entrepreneur and owning your own business you can only write yourself a paycheck if your providers pay you. You need an understanding with your providers as to when you are going to be paid for your services. Doctors are often not the best businessmen and are sometimes not very good about paying bills on time. Especially when you are first starting your business it is vital that your provider understands when you expect payment and that you have something well written to protect you if you end up with someone interpreting the language of your contract in court.

Each year you are in business you find additional things that need to be added to your contract. New situations arise that you realize should be covered in your contract. So how do you cover everything that needs to be covered? You need a list – actually several lists. You need a list of what you feel the provider’s responsibilities are. You need a list of what you feel your responsibilities are. You want to imagine a symbiotic relationship with your providers and then list the reasons this relationship works and put those actions in your contract as responsibilities of yourself or the provider.

You need a list of everything that you have ever heard of going wrong in a medical billing business between the provider and the biller. You need to decide how you would avoid those situations if possible and cover how it would best be handled in your contract if unavoidable.

What you are charging your provider and how you will get paid is a fairly important part of your contract. Are you charging a percentage, a flat rate, or a per claim fee? Is it clearly defined how you are charging? Is the percentage on what is billed out or what is received? Are patient payments included? If charging per claim, what constitutes a claim? Is it a line on a claim form or is it per page?

You also need to take into account what will happen when the relationship ends. It may be expected, as when someone retires, or it may be unexpected but you need to have a plan in place for when the relationship ends. It will be a much better parting of ways if you have a plan of action for how things will be handled.

The whole reason for a good contract is to protect you but your contract can do much more than protect. You can weed out potential problem providers that will drive you crazy. If you are not in agreement with your providers on what each of you will be contributing to the relationship then the likelihood of the account going smoothly is very small. Don’t make the mistake of skimping on an important part of your business that may save you from defending yourself in court down the road. Make sure you take the time and experience of others to get everything you need covered in your contract.

Drawing up a business plan is one of the initial steps in setting up the medical billing business. Before that, the form of business organization you want to set up has to be finalized – whether a sole proprietorship, partnership or a corporation. All the formalities like registration, permits and licenses and other requirements as mandated by law need to be fulfilled before starting operations. Simultaneously, a name has to be conceived for the new business.

The best of business models can go haywire if there are cost over-runs. Hence, having an investment budget in place is of utmost importance. The start-up cost will depend on a few factors such as your risk-taking ability, business requirements, the type of equipments to be sourced, etc. The minimum seed capital can be anywhere between $3,000 to $5,000. A few basic things required for smooth operation will include computers, fax, modems and internet connections, back-up systems (to prevent the data from going kaput!) and last but not the least, office supplies. Insurance forms, coding and other reference books, medical billing software and office furnishings will form a part of the initial expenses that will chip off a major chunk of your seed capital. Just the medical billing software can set you back by around $500.

You need to do a bit of research before you zero in on the best software for your business. Stick to software that can be updated as your business grows. A software provider with good after-sales service should be given preference at the time of finalizing the chosen provider. Always ask for a demo so that you get first-hand experience of the software.

To market your business is the next step which will need a great deal of time, money and energy. Getting clients can be an uphill task if you are not aggressive. It is advisable to start locally and make a list of doctors in the vicinity. To get started source the list from a list vendor for a fee. Next, send e-mails or direct mails with brochure, detailing the service that you offer. Immediately follow-up your mailings with phone calls. This will create an impression in the prospective client that you mean business.

Put up a website. Blogs can be an effective tool to market your business. Cold calls can be resorted to but it is not advisable, since doctors are sometimes involved in emergency situations and may not appreciate being interrupted. Hence, the next best option is to leave your business cards and other marketing materials with the receptionists.

Using referrals is another age-old technique to gather clients. You can begin with approaching your family doctor, introduce your business to him and ask for referrals to other doctors who may need your services. As you build customers, use referrals to grow your business since it is the most cost effective way to grow your business.

Offering value-added services is a sure-shot method to provide your business the needed impetus. The growth of your business is directly proportional to the degree and level of satisfaction of your client/customer. Provide additional services like electronic fund transfer “EFT”, third-party collection service, remote back-up service, and digital scanning of medical records.

The economy is in recession and most doctors want to lower their costs and improve collections. It is a great time to start a medical billing service.

First of all medical billing and coding are basically two different functions. You can focus on billing or medical coding or a combination of both. Oftentimes people think you must train in both billing and coding but that’s not the case. Oftentimes in the company you work for as a medical biller you’ll receive work that comes to you already coded.

So you could be on the coding end or billing end. Some companies do both in-house. But the simplest and most effective route is to focus on one or the other. Both require training usually and to add coding you would have to add quite a bit of training. If you just take medical billing training, course or a program you can get your training done and get your certificate, in some cases, and you’re ready to get a job.

One of your concerns of course will be to find out how much money you’ll make as a medical biller, billing specialist or assistant, medical coder or medical insurance specialist. When you start checking around and looking for jobs you will find that the titles come by various names. So keep that in mind. A medical insurance specialist usually does both billing and coding.

The kind of money you’ll make as a biller or coder will depend on how much experience you have and what billing and/or coding training you have. At a bare minimum you should be able to get a wage of at least $12 to $15 an hour starting out. The more recent and long-term experience you have will increase your job starting salary quite a bit.

So you can see that the level of education you have, whether you have a certificate or not and amount of experience will be a factor in the salary you receive. Check all your local job sources and human resource departments at hospitals, clinics and insurance companies to see if you can get an idea of job requirements and salary range for specific jobs they have opening for. A medical billing certificate is not always necessary. A trade school, vocational, billing or coding school gives out their own certificates plus there are national exams you can take and pass to earn a certificate in your field also – for example as a Medical Billing Specialist. Local colleges and universities have billing or coding classes and programs in some cases.

You need to check with your local schools and compare them with online schools. Make sure you understand what you’re signing if you’re asked to sign a contract for any online education. Your local colleges may also have online programs so you can get the medical billing and coding education you need that way also. Federal financial aid and money is set aside for online classes also.

Never bring a knife to a gunfight.

Sean Connery, the Untouchables

Thirty years ago, one of our billing office employees told me an interesting story. While previously working for a large insurance company she had been instructed to throw away every third batch of bills. The insurance companies knew that many of these claims would never be followed-up, further increasing their profits.

Although many things have changed in 30 years, health insurers are still inventing new and creative ways to avoid paying providers. Companies still routinely deny, underpay or delay payments, both to practitioners and hospitals. The cited article is about a settlement against the major carriers for these offenses in California.

Many of the techniques are not new. Legitimate bills are not paid, and inquires are met with old standby tricks like rude, under-trained employees, multiple similar sounding plans, and slow payments. However the insurance companies have a very powerful new weapon, mind-numbing complexity. Smart computer scientists have built billion dollar systems to exponentially increase the requirements for claim submission. Any deviation from these arcane rules will be identified and flagged as a reason for denial. The process is further complicated by frequent and ambiguous rule changes, which are often not published, and can only be inferred from the pattern of rejections.

The resulting mismatch is equivalent of bringing a knife to a gunfight. Individual providers, larger groups and hospitals do not have the resources to successfully confront the computer and software firepower deployed by the insurance companies. When faced with an incomprehensible, unexplained, and frequently incorrect rejection, poorly trained and overworked billing office personal are forced into the cavernous abyss of the appeals process, designed to further frustrate, confuse and delay. Up to 1/3 of doctors bills are not properly paid, in large part due to the success of the insurance company tactics.

Although the California legislature acknowledged the issue(many states haven’t even gone this far), the insurance companies managed to make certain the penalties would be trivial. The fines are totally inconsequential to the bottom lines of these multi-billion dollar companies.

The vital point for the health care provider to understand is that there will be no “rescue” by the legislature, the medical societies, or the goodwill of insurance companies. Anyone submitting bills on a regular basis needs to take responsibility and obtain the tools to win the battle against these corporate behemoths. I helped start Vericle to even the odds in this battle. Yuval and his team have developed the tools that enable the provider to thrive on the complexity. Insurance companies are bullies, and will back down when confronted with a comprehensive and powerful system that calls their bluff. Vericle is such a system.

Readers must realize that the complex systems arrayed against the practitioner cannot be defeated by moral rectitude and hard work. Being right helps, but don’t forget your gun.

Reference: Duke Helfand, “California’s largest health plans are fined nearly $5 million,” Los Angeles Times, November 30, 2010

As we embark upon 2011, the necessity to improve the efficiency and profitability of our Medical Billing has never been more important. In the face of rising practice costs coupled with declining or stagnant reimbursement, the challenges presented to medical professionals and their billers will be daunting. Many billing operations have not kept up with the ever-changing challenges and the risks to their practices, and this will become very apparent in the New Year. Here are some suggestions to assist your medical billers and some deadly pitfalls to avoid.

• Hire the right person for the job. With a myriad of “Get rich quick doing medical billing” courses being offered throughout our communities, the need has never been greater to insure a quality vetting process for hiring the best billers. Many of these medical billing courses are vastly inadequate in preparing billers for real world practices. Greater hiring success can be achieved by developing your own standardized testing for all new applicants as well as thoroughly checking references and verifying stated qualifications.
• Use Your Practice Management System to its Full Potential. The days of your old management system are over! With the demands placed on the ever-changing billing software programs, having a modern up-to-date system in place and having people who know how to fully utilize it, is critical. Blaming a management system for all of our billing woes is easy, but inappropriate. Proper training of personnel and having a relationship with your software vendor is the key to solving most of system problems you face. Reaching out to other practices with the same software is another suggestion, to tap into their expertise and experience.
• It’s the Insurance Payers Fault! It is overly simplistic to blame the insurance payers for our increasing denials, more write-offs and reimbursement rates that have fallen off a cliff. The old adage that, “it is what it is”, is unacceptable. What we shouldn’t do is throw up our hands in disgust and accept poor payer performance. Look inside your own company for ways to tackle repetitive issues with different insurance payers. Keep journals for payer specific companies and what has improved performance. All payers are not alike and what may work well with one may have no bearing on another. Successful billers who deal with multiple payers will address both internal and external issues for increasing overall payer performance.
• Prioritize-NOW. With a desk heaving over with work and 200 emails to read, the ability to prioritize and properly manage workloads is imperative. Developing schedules and checklists of the most to least important functions of the day can assist your billers, especially the newer ones. Being unable to recognize what is more important over what can wait, has been the downfall of many well-intentioned billers. Taking a logical and deliberate approach to your workload is critical to your success.
• What Write off? Wouldn’t it be so much easier just to write this off? NO! A common pitfall to new and experienced billers alike is to take the easy way out and write off denials. These inappropriate write offs cost practices thousands of dollars a year, that could just as easily be recovered with a little effort. It oftentimes seems like the insurance companies’ front line of defense is to deny claims. Perhaps the lazy billers in our midst have propelled this practice into something that is now commonplace. Working denials and writing appeals should be a tool that is readily used by every biller. The result of this effort will either show flaws in your billing practices or educate your billers and physicians on what and how line items and even times, entire claims get paid or denied. When we understand the real reason for denials, then we can properly address those items, with educated practices that reduce the write offs and increase reimbursements. Don’t take the easy way out!
• The Perfect Billing Office. While we would all like to think that ours is the best, realistic managers know that there is always room for improvement in any operation. With the complex nature and demands in Medical Billing, the many little things degrading performance can easily be missed. Closely monitoring performance, in all areas of your business is the never ending key to success. Every office should develop a template of key performance indicators. This could include A/R, write offs (see above), aged trial balance or whatever you deem to be key indicators of performance for a specific account or practice. All participants should agree on the way information is gathered and input so this isn’t an exercise in “garbage in-garbage out.” A monthly monitoring and discussion is invaluable as well as sharing the information gathered with all involved and eliciting staff input for improvements.
• Just a Cog in the Wheel. Understanding the duties and responsibilities of every aspect of the medical practice is vitally important to the efficient running of the entire operation. It does little good to have an outstanding coder when a physician won’t complete his chart notes in a timely manner. When one aspect breaks down, it negatively impacts the whole practice. Maintaining consistent revenue is a goal that can only be achieved by seeing the big picture. The smooth relationships and interaction of all these cogs in the wheel, affect the ultimate outcome. Provider enrollment and negotiating contracts lays a critical foundation. All staff members understanding how their specific involvement and duties affects the entire process is imperative. Allowing one aspect to bog down is detrimental to the entire operation. Thorough monitoring and quick corrections to deficiencies and inadequacies should be job one for a successful office.
• Welcome to the 21stCentury. With the increasing demands on our billing offices to achieve more with less, we are fortunate to have access to the latest technology. Offices that fail to keep up with the times and utilize the resources that are available will quickly become obsolete and fail. With the increasing focus on electronic medical records, having a quality EMR system is critical. It is foolhardy to not take advantage of the all the advances in current medical billing software that can complete or expedite many tasks such as scrubbing claims, electronic remittance, using predictive dialers, automating charge capture data, and many other applications. At the bare minimum, an office evaluation by a medical billing IT professional can help streamline your office systems and insure you are running at maximum efficiency.
• Where Did My Money Go? Companies with fewer than 100 employees are most likely to suffer internal fraud. Small companies tend not to have adequate control systems to prevent theft, and individuals are put into responsible positions with relatively little oversight. Medical practices are especially susceptible to this type of theft with as many as two out of three physicians becoming victims of embezzlement at some time in their career. One reason medical practices can be vulnerable to embezzlement is that they often have numerous cash transactions for out-of-pocket payments, co-payments and deductibles. Many medical practices turn over complete control of their cash and checks to office staff, increasing the potential for internal theft. A medical practice can lose thousands of dollars because of just one dishonest employee. If your practice is not careful, your profitability could be jeopardized by a staff member falsifying records, creating fake patient accounts or conspiring with vendors. By establishing a strong, formalized system of controls to monitor money, employees will understand that honesty is both valued and expected.
• Let’s Go Paperless! With modern technology the idea of a nearly paperless office appeals to many, and is ever closer. Transitioning workers accustomed to the paper trail is a sometimes difficult process. Paper pushers tend to spend an inordinate amount of time managing all their papers. Their papers must be organized, highlighted, stacked, placed in folders, etc. Properly training staff in the efficient use of computer software intended to replace paper, leads to increased production and a streamlined workflow. Having policies and procedures in place that discourage needless paper and require more efficient work, are valuable tools in encouraging your staff to be more productive.

New Year’s resolutions are ever so popular in our personal lives. The resolution to make your office more streamlined and efficient should be a daily vow. With the unknown impact of the changes in healthcare on the horizon, there is no time like the present to insure you are fully utilizing all of the technology and information available to make your office the best it can be.

We all understand how health insurance generates a lot of paperwork which also includes a lot of fine print. However, the bad part of this is that most folks tend to not read any of this in as a result do not understand what your plan covers. They are unaware of the fact that health insurance coverage can have many limitations.

Unfortunately, too many people find out the pitfalls of health insurance through a disastrous event that they either read about, hear about, or even experience. An example is that lots of patients have found that their medical plan would not cover certain medical procedures because they didn’t get the proper authorization code prior to the procedure taking place. Often times, many of these claims are subsequently covered but the process is extremely tedious. It is this lack of cooperation by the health insurance company where many patients simply give up trying to get their medical bills paid.

Another type of health insurance limitation is one that happens too frequently. This happens when the patient is diagnosed with a condition that needs a specific operation. They then research all the surgeons and hospitals within the scope of their medical plan. After deciding, they go in with the procedure only to find a ton of medical bills in their mailbox. What they discover is that their medical plan does not cover all the fees charged by the specialists for their services, such as that of an anesthesiologist. The patient then has to pay all those additional fees.

The only way to avoid all these additional fees is to make sure you find out about how many specialists will be involved in the procedure before the fact. Then you have to make sure that your insurance plan will cover those things. This type of due diligence is not typically utilize by most people.

Do not make the mistake of thinking that just because you have health insurance that you are fully covered as this is only to a certain point. You should make it a point to read your health insurance plan thoroughly and consult your plan administrator as well as your doctor before agreeing to a medical procedure.

When a person has a health insurance from a certain company, he/she is probably familiar with the process called medical billing. It is actually the process in which a medical billing specialist files a claim to the patient’s health insurance company. This a way of making sure that the health care providers will be able to receive the appropriate payment for the medical services that were rendered to the patient. With this process the billing specialist will also deal with unpaid claims and other problems related to related to it.

To determine the medical service that has to be billed to the company, the patient’s condition and some background health information will be evaluated. Then, different codes that correspond to the procedure and diagnosis will be generated which will then be transmitted to the insurance company for the payment. But it may take from days to months for the process to be completed. This particular process is used for almost all insurance companies regardless if it’s a private insurance company or if it’s owned by the government.

In the past, claims were usually files using a form. The form can either be a CMS-1500 or HICF. But at present as the technology rapidly advances, the billing process is already done using such technology. Instead of sending a paper claim form, billing specialists file their claims to the concerned insurance company electronically. However, before health services are rendered to the patient by health care providers, they use a software first that will verify to the company if the patient is qualified for a particular service. Then after checking the eligibility, only then that the service can be rendered.

After submitting the claim, the insurance company will then confirm the receipt of the claim and lets the other party know that it will still be subject for further checking, reviewing and processing. And after a certain period of time, the company will then provide necessary information on whether or not the claim will be paid, the amount if it will be paid or the main reason if it will not be paid. Obviously if the claim will be paid, no further processing will be done but if it’s not going to be paid, the billing specialist has to make necessary corrections basing on the reason given and resubmit the claim until it will finally be paid.

With this process, everything is definitely made faster and easier compared to manual process used before. But of course, in order to get the claim paid in a shorter period of time, the billing specialist has to know almost everything regarding the different insurance plans offered by different insurance companies. This is easier to be said than done considering that a big insurance company, alone, can offer more than 10 different insurance plans all at the same time. He/she also has to know the coverage of the plans as well as the rules and regulations related to filing claims. With all these knowledge, then the medical billing process won’t as hard as you might think it is.