Rz8DtqjoMkjmg3QBXVQj5Bg7wspzYBXig: December 2012

Sunday, December 9, 2012

Why Work in Medical Billing and Coding?

If the field of medical coding and billing sounds interesting to you then check out these reasons as to why one should work in this area? The reasons are:

• One of the reasons why the field of medical coding and billing is so lucrative is the fact that anyone can learn it within a year or so. Depending upon the course and school you choose you can pass with a diploma in medical billing and coding in a year or even have a certification in 2 years.

• This career path allows you to work from home. You can either start your own medical coding and billing company or can work for some other company. In both the cases the rewards are very high. Clinics and hospitals do not handle the medical insurance documents on their own and normally require the services of medical coding and billing companies. Working from home is a great option for freelancers who enjoy working from home or for housewives who have the zeal to work but were not able to do so because of other responsibilities.

• The job of medical billers and coders is just the starting point for these medical billing and coding professionals. With experience and expertise in the medical field you can diversify your career and go in for various other job designations.

• Once you have gained some experience working as a professional medical biller and coder you can opt to quit your job and start your own company. Starting a company is a big step and this decision should not be taken lightly.

• Due to the everlasting increase in the demand for health care facilities one can be sure that going in for a medical billing and coding course will give you the much needed job security.

How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option Important Difference in UK Vs US Health Insurance Models How Under-Coding Affects the Financial Well-Being of Your Medical Practice

The Politics of Preventive Medicine

"The most costly of all follies is to believe passionately in the palpably not true."

HL Menken

A recurring theme of mine is the maddening, confounding and fascinating complexity of human health and disease. Common sense, unifying principles, and single-explanation theories cannot encompass the diversity of the human organism. Easily understandable, common sense approaches to health care can often be ineffective or counterproductive. Lay people and their political representatives rarely grasp these intricacies, which leads to poor individual choices and public policy.

Obamacare panders to these tendencies by stressing "preventive care" as a core principle. What could be more sensible and cost-effective than preventing disease by finding it early? Two papers published last week seriously question these underlying assumptions and raise fundamental issues about the integrity of the medical foundations of Obamacare.

The first paper is about prostate screening. The conclusion is that finding tumors early has no impact on the life or health of the people screened. This counter-intuitive outcome is based upon the unusual behavior of some of the prostate cancers found. It appears than many cancers never progress far enough to cause any actual problems. Screening finds these harmless tumors, and treating them results in no benefit, and greatly increased cost. Waiting to treat those cancers which actually do cause problems is just as effective. Needless to say, this kind of result is difficult for many people, even some physicians, to accept.

The second paper is about mammography (disclosure: I derive income from billing for radiologists performing mammography). This detailed study questions the role of mammography in the reduction of breast cancer mortality. Although there has been a substantial reduction in breast cancer mortality since mammography has become widespread, there has also been dramatic improvement in various therapies. The study questions the portion of survival benefit attributable to mammography, which may be smaller than either simple reasoning or prior studies suggest. Again, this finding is strongly counter-intuitive. Common sense would dictate finding a cancer earlier would be of great benefit, but common sense might be wrong.

Other "preventive" measures, mandated by Obamacare, including weight loss and smoking cessation counseling, are also essentially worthless. A strong anti-smoking lobby and weight loss industry has influenced Congress to include expensive counseling and education programs in the mandated insurance coverage, which have been proven by many studies to be ineffective. Demanding insurance companies pay for such services will be costly and of little benefit to all but those selling the services.

From a health care policy viewpoint, the money, time, and effort spent on these "preventive" measures will be wasted. Compelling insurance companies to cover such services, cost free under Obamacare, is not supported by "evidence based" medicine. Obamacare's backers hypocritically reject overwhelming evidence if it does not support their political agenda. However, they are quick to accept borderline data in order to malign therapies not so politically popular. Removing Tonsils and Adenoids was singled out by President Obama as a wasteful and expensive therapy. In actuality, the evidence about this surgery is not conclusive, and many children (including my own) demonstrate great benefit. It seems the political connections of the supporters of a therapy are more important than the medical evidence.

These ill-conceived policies represent the triumph of politics and lobbying over medical science. Obamacare is not about health, but reflects the economic and political power of the constituencies trying to manipulate the dollars behind it. The process has also further eroded what little trust Congress held for the American people. Costly, useless, fanciful, and doomed to fail, not a good prognosis for Obamacare, or the health of America.

Eva von Schaper, "Prostate Screening Fails to Cut Cancer Deaths, Study Says. Bloomberg news, September 14, 2010 Anthony B. Miller, MB, FRCP; Teresa To, PhD; Cornelia J. Baines, MD; and Claus Wall, MSc, "The Canadian National Breast Screening Study-1: Breast Cancer Mortality after 11 to 16 Years of Follow-up - A Randomized Screening Trial of Mammography in Women Age 40 to 49 Years," September 3, 2002, Annals of Internal Medicine, Volume 137, Number 5 (Part 1) E-315 How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option How Under-Coding Affects the Financial Well-Being of Your Medical Practice TV Medical Leads

Need a Medical Coding Update? Audio Conferences Can Help You

In today's complex regulatory environment, what with healthcare resources stretched to the limit, you need to optimize your coding and compliance efforts. A good way to do so is by signing up for audio conferences. When you sign up for one, you will get a medical coding update, inside scoop on how to tackle the coding issues that are costing you money and putting you at risk for a bad audit, and lots more.

When you get onboard such a conference, you will get an idea where you are losing money, get the lowdown on the most common missed reimbursement opportunities, it'll help you get the latest update on regulatory issues, ways to analyze your billing performance and tips and tricks to make every appeal a success!

When you sign up for one, you will be able to save on your travel costs as you can listen to them from the comforts of your own office or meeting room. Such a conference provides multiple formats to fit your training needs. And the best part is such conferences can be had in CDs or PDF transcript.

One more advantage of audio conferences is that you can even gather around a speaker phone or computer and train your team at a small price. Post the conference, you can take active part in the Q&A session. And after every conference, the presentation materials are yours for keeps.

But the best part of such audio conference is that you can earn CEUs from them. So go sign up for one today!

How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option How Under-Coding Affects the Financial Well-Being of Your Medical Practice TV Medical Leads Important Difference in UK Vs US Health Insurance Models

7 Steps to Getting Experimental Surgery Authorized

Do you need experimental surgery or this is what your insurance company called it. Is it really experimental surgery? How many times has it been performed? Who performed it? Before you hear from your medical insurance the procedure your doctor wants to perform is considered experimental, too expensive, the statistics are low for the surgery to be beneficial. Think again.

Your medical insurance said they will not pay for the surgery what is your next step?

Calm down think logically. You need to appeal!! You need this surgery to save your life or limb.

These are the questions you need to ask yourself?

1. Is this the surgical procedure I really need?

2. Is there another surgery which is better?

3. Is the surgeon that really can perform this particular surgery on your medical plan or is the surgeon out of network?

4. What will be the entire cost of the surgery?

5. HOW DO I GET MY MEDICAL INSURANCE TO PAY FOR THE SURGICAL PROCEDURE?

BREAK DOWN OF CHARGES:

a. Charge of operating room?

b. Charge for surgeon?

c. Charge for assistant surgeon?

d. Charge for anesthesiologist?

e. Charge for Laboratory?

f. Charge for X-rays?

g. Charge for unknown?

1. You can get this information simply by calling your doctor's office. There will be somebody whose job it is to get this information to you.

With this information in hand you will now have a substantial plan in hand.

2. Another vital part of your appeal is getting the names of people who have had this experimental procedure performed and your insurance company has paid for it. You will need a list of their names, date of surgery, the name of surgeon, the surgical procedure performed.

You can get this information by requesting it online at any of the popular websites. Make sure you include in your request why you need this information. Include your contact information (name and email address)

This is the time to think outside of the box to get all the information you need, what phone calls to make, and what websites can get you the information you need.

3. If the surgeon you want actually performs this particular surgical procedure, is on another medical plan, you must get this same estimate from that physician's office.

You can then do a cost comparison.

In an appeal letter in which the surgical procedure you need has been denied, ask the insurance company what form of MEDICAL NECESSITY information they need.

4. What is in your contract about this type of appeal procedure?

You can get some of this information off the internet in your medical insurance company's website. If you can't get everything you need call and ask them to mail it. Make sure whatever you receive you send back to them in the appeal package.

5. Always send medical records with your appeal. You can request them in writing from your physicians, hospital, x-ray, lab, ambulance, etc.

6.. Fax your appeal letter and all your documents the more documents the better make it at least 20 plus pages.

Get to the top person in your medical insurance company.

Do your homework.

Use your computer or start calling and asking for the CEO's phone number, fax number and email #.

The president, vice presidents any body in power.

Then fax all this information marked Urgent Expedite Immediately and I would add Personal and Confidential.

Fax this at midnight on Sunday night.

Fax it to everybody you can get their fax #s.

Make sure you change the Fax information sheet.

The name of the person being faxed, title, your name, Appeal Letter for Specific Surgery

CPT and ICD numbers. CPT numbers is the reason for the visit Example: Doctors Visit, ICD is the medical diagnosis Example: Ear infection.

How many pages and your contact information which includes not only your name, phone number, email address, your insurance identification number.

I would also Email it all at the same time to each person. Do not forget anybody.

This is a life or death situation and you can put this appeal letter together with the guide lines above.

Remember money talks and if you can prove the surgeon you want (not the one the insurance company will give you) will be paid at the same rate, you have a great chance of getting your appeal paid.

Everything is negotiable in medical insurance. If this surgeon or hospital or both are out of net-work the payment can be negotiated by the insurance companies.

Experimental Surgery Authorized What About the Doctor

The experimental surgical procedure has been approved. Yeah!

Now is your battle really over? If this is experimental surgery there are not many doctor's which will do this very new surgical procedure.

Now is the time for you to do your homework. What is the name of the doctor who does this particular surgical procedure? How do I get this doctor to do the procedure for me and get my insurance company to pay for it, even if it is out- of-network.

Now you need to write another appeal letter.

You do a cost comparison between the doctor your insurance company picked and the doctor you want to perform your surgical procedure. See above.

You can get statements in writing (if possible) from physicians who are picked to perform this experimental procedure to say they do not do this kind of procedure they work in another part of the body. They make charge you.

The important thing is get your surgical procedure authorized, get the right physician and have a great life. Thank you for reading my article. Please feel free to read any of my various articles on numerous subjects. Linda E. Meckler copyright

Malpractice - It Is Personal

It's been a year since my trial, and five years since the elderly man came into the ED in shock. The trial came much later, of course, after years of depositions, most of which I insisted on attending. The trial itself is best described as life-changing: six days of humiliation and accusations, all the while being told that it was nothing personal.

It felt very personal when they questioned my honesty, morals, and intelligence. It felt personal when they didn't miss a chance to accuse me of recklessness, stupidity, arrogance, and laziness. It felt very personal when they asked for an award far more than my policy limits, and I, as the sole defendant, had to imagine the possibility of losing my house, retirement savings, and kids' college fund. Through a stroke of luck, the jury returned a decision for the defense. No one will convince me that on another day, a different group of 12 people could not have found me guilty, and awarded my future to the plaintiff.

Dr. George Hossfeld, Assistant Professor Emergency Medicine, University of Illinois-Chicago

One of my recurring topics is the gap of understanding between physicians and those attempting to reform medical care. No greater disconnect exists than between doctors and outsiders than their attitude toward medical malpractice. As illustrated in the above quote and as mentioned previous blogs, this visceral issue may be the most important factor undermining social contract between physicians and society. Congress does not understand the non-economic, "black swan" impact of medical malpractice on the physician, which may doom all attempts to cut medical costs.

For doctors, malpractice is personal, but for Congress it is all about business, often their own. Trial attorneys are one of the largest political contributors and are substantial backers of Obama and Biden. Senator John Edwards made his fortune suing doctors. Malpractice attorneys point to the statistic that only 2% of medical costs are directly related to malpractice, and many patients are severely injured or killed by medical incompetence. This is a complex issue, with good arguments on both sides, however it is clear that most money spent on malpractice litigation goes to lawyers not patients, and the legal profession's motivation is not the health of the American people.

The most important impact our malpractice system may have is on doctor behavior. Being involved in such a lawsuit, or even hearing about one, changes behavior forever. Avoiding the pain or litigation never leaves consciousness, and often becomes the overriding consideration for how doctors perform their duties. This worry about malpractice will prevent the transition for "exception based" medicine to the "evidence based" medicine touted by Dr. Berwick and other Obamacare advocates.

As long as the specter of malpractice looms doctors will continue to do expensive tests for low probability diseases. The tiny risk of malpractice litigation overwhelms all learning, evidence and reason. "I was sued once" spoken by a colleague becomes the final arbiter of medical decision making. One missed case of coronary disease in a young patient justifies thousands of negative blood tests, no matter what the "evidence".

Estimates are that 20-30% of medical costs are related to malpractice avoidance. These numbers may understate the problem, as malpractice concern permeates the entire medical enterprise. The "reformers" point to these statistics as a potential source for huge savings by avoiding these unnecessary studies. However, without simultaneous dramatic change in the malpractice process, doctors will not change their behavior. The reforms required will require more than monetary limits. The entire process needs to be changed. More later.

http://journals.lww.com/em-news/pages/articleviewer.aspx?year=2009&issue=01000&article=00003&type=fulltext

http://www.insurance-reform.org/issues/MedMalSystemCostsFactSheet2009F.html

A Medical Billing and Coding Salary Can Be Yours For the Taking

Your medical billing and coding salary, should you decide to enter this sector of the healthcare industry, will vary somewhat depending on a number of factors. The first is your geographical location. Your medical billing and coding salary is likely to be better if you work in a big city like Boston, Chicago, Houston, or New York, as salaries reflect the higher cost of living. Also there are more, larger organisations like nursing homes and hospitals that are able to afford better rates, than a typical small town doctor's office. Remember though, that responsibilities and work load may be higher working for a larger organisation.

Having a certificate or degree is not essential to command a good medical billing and coding salary, but it certainly helps, and those with qualifications will be likely to achieve better rates of remuneration.

The American Academy of Professional Codes (AAPC), has quoted salary figures in the region of $30,000 per year for a non-certified coder, and up to $38,000 for a certified one. These are only averages but it seems well worth going the extra mile to take the certification exam.

Medical coding and medical billing are separate specialities, yet they are closely associated and overlap somewhat, so that a person who is accomplished in both areas of expertise is more valuable to an employer than just a coder or billing specialist. If you are able, it is well worth taking a course that covers both aspects of healthcare payment administration.

Another important factor in respect of a medical billing and coding salary is experience. Somebody who is experienced is likely to be able to work faster, and with greater confidence than an inexperienced person, as they will be familiar with lots of codes without necessarily having to look them up all the time. Thus experience leads to increased productivity, and a person who is really good at the job can command a salary as high as $50,000 per year. An experienced person also knows about all the rules and regulations governing the job, and will have developed a workable modus operandi.

Instead of working for a fixed salary in an organisation, it is possible to operate as an independent contractor from home. This enables you to have flexible hours and take on as much work as you have the time to do, provided, of course, that you have sufficient clients. You would then be paid by the hour, at a rate of perhaps, $10-12 per hour, depending on your certification and level of experience. This way of working is not likely to be as remunerative as full-time employment on a fixed salary, but may suit someone with other responsibilities, or who is unable, or, does not wish to travel.

One needs, though, to be aware of scams and bogus job offers that are rife these days, especially in the work-at-home area, and offered on the internet with heavily persuasive copy.

There is, however, little doubt that someone conscientious and accomplished can earn a very fair medical billing and coding salary.

Hospital Bills - Plan Ahead to Avoid Costly Mistakes

Understand your insurance policy terms and hidden rules before choosing a hospital for an upcoming medical need. If your circumstances dictate the need for an out of network hospital understand the practices behind usual customary and reasonable charges - or you may find yourself in the poor house.

I recently underwent a surgery that required a five night hospital stay. The final bill from the hospital sheds light on an often misunderstood and potentially crippling aspect of medical billing: usual customary and reasonable charges. If you are considering being treated at an out of network hospital, make sure you understand your possible financial obligations.

Many insurance plans provide in network and out of network reimbursement. The typical plan pays a higher percentage of charges for in network hospitals, and a lower reimbursement percentage for out of network providers. What many people fail to realize is that reimbursement levels are based upon usual customary and reasonable charges. If your hospital bills you above these standard rates you may be left with a big problem.

My surgery was performed at an in network hospital, and my insurance paid 100% of the "allowed charges", after I made a daily co payment. The total hospital charges were $61,000, while the allowed charges were only $13,000. The hospital credited a $48,000 contractual adjustment - that's a 78% discount off the retail cost!

When you use out of network providers you lose cost containment: the contractual rate. If this hospital was out of network my insurance would have paid 80% of the allowed charges - or $10,400 leaving me with an unpaid hospital bill of over $50,000. The contractual rate is equivalent to usual customary and reasonable fees and medical providers are free to charge and collect on any differences. In many cases the difference can blow your mind and your budget.

For many, an out of network hospital may be the best option for a healthy outcome. Make sure you know the real cost before making your choice. Hospital indemnity insurance can help as well, and long as your coverage begins before you need it.

How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option TV Medical Leads

Section 111 Reporting - Special Issues in Mass Tort Claims

Section 111 of MMSEA Reporting Requirements

With Mandatory Insurer Reporting set to finally take effect on January 1, 2011, the insurance industry, litigants, beneficiaries and legal practitioners continue to face uncertainty regarding Medicare, Medicaid and SCHIP Extension Act (MMSEA) Section 111 Reporting Requirements.

This is particularly true in mass tort litigation. Unlike a more standard tort claim, mass tort litigation presents unique challenges from both a practical and Medicare Compliance standpoint. Clearly, the burden on the parties to comply and cooperate with the mandatory insurer reporting process impacts all facets of mass tort litigation as it does all tort litigation.

No Section 111 Resolution Section 111 reporting issues have not, by any stretch of the imagination, been resolved with respect to standard tort claims. Despite ongoing testing and receipt of data, CMS continually reworks the technical requirements of the reporting process and periodically clarifies critical elements of the reporting obligation such as the Ongoing Responsibility for Medical Care and what insurance products may be considered "no-fault" insurance.

Some unique issues raised in mass tort claims include proper and timely identification of Medicare status of class members, uncertainty regarding a specific product or products at issue in the litigation and the use of settlement funds or trusts.

Trusts sometimes make it difficult to identify the final recipient of funds and the amount ultimately received. Even less guidance has been provided by Centers for Medicare and Medicaid Services (CMS) regarding mass tort claims. CMS has been accepting comments and suggestions for revision of the "Product Liability" reporting fields including limiting the level of detail required and revising the term "Product Liability" itself to more accurately reflect the underlying legal issues.

We eagerly await the release of User Guide (now anticipated in July, 2010) which, CMS promises, will clarify their policy decisions and provide practical guidance on reporting for mass tort claims. They will include information on bankruptcy and insolvency, as well.

Take Medical Coding Or Medical Billing Training Online Or On Campus? - And Know These Job Secrets!

If you're thinking about going to school online or on your local campus to get trained in medical billing and/or medical coding you'll find you have many options. There are many medical billing schools, trade schools, colleges and universities that advertise training online and offline. It may seem simple enough but it's important to look at all the ways you can get educated if your interest is in either medical billing or medical coding or both.

Medical billing and medical coding are two separate functions. You can be an expert in billing or coding or both but the training for each is quite different and usually people specialize in one or the other. Those who choose to be educated in both fields are usually known as medical insurance specialists. Most often though you would find yourself employed in facility such as a billing service or large doctors clinic or hospital and be hired to do just billing or just coding.

First of all you want to research all the schools online that offer specifically programs in either medical billing or medical coding and find out exactly what these programs cost and what classes they consist of. You need to know if you're required to take every class offered or if there is a bare minimum of classes you can take. Many schools add on classes you don't need. Many of these schools offer a graduation certificate but this is not the same certificate that the national associations offer if you decide you want to take a national exam to be certified. You may find some of these schools can be expensive. Make sure you get all the financial details.

Then the next step is to contact all your local schools, trade schools, college and universities and find out if they have any medical billing or medical coding programs set up or if they have any classes specifically meant to train you in these fields. Some schools have programs set up and you need to find out exactly what the program consists of and the cost or classes and the cost.

The most important thing is to know that you'll be able to get a job in your city or town after your medical billing training or medical coding training is complete. The education won't make a bit of difference if you can't get a job after you're done. So make sure to call the human resources department at local billing services, large clinics and hospitals and find out what the job opportunities are for medical billers and medical coders. But do all your online research first so you know whether or not you can afford to go to school or not. There is plenty of federal money available for online classes as well as for on your local on-campus training.

How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option How Under-Coding Affects the Financial Well-Being of Your Medical Practice Important Difference in UK Vs US Health Insurance Models

Medical Reimbursement is All About Follow-Up

So here's how it works: You see a patient, your biller submits a claim, and you get paid. Right? The answer, of course, is "no." The ugly truth is that many claims are never adjudicated. Why not? The claim was never received, it was sent back to the plan for pricing, the hand-off from one clearinghouse to another didn't happen, the gatekeeper computers rejected it, it's being held for additional funding from a self-insured employer, the carrier changed its "edits" so their computer now rejects claims that it used to accept, and oh, this network no longer handles those claims.

Because the claim doesn't get adjudicated, you don't receive a denial, and you don't know there was ever a problem. Meanwhile, most billers are so busy submitting claims and posting payments, that as long as you're not asking about missing revenues, those lost claims stay lost forever. Granted, some billers faithfully hit the resubmit button every 30 days for unpaid claims, but if they didn't uncover and address whatever issue prevented adjudication in the first place, those resubmitted claims fall into the same black hole until the timely filing limits expire.

Which brings us to this: The three most important things about medical reimbursement are follow-up, follow-up, follow up.

If you want to get paid for those "lost" claims, your biller has to read reports and work the phone. Someone has to ask, "did you receive this claim, and if so why hasn't it been paid?" Unfortunately, most billers focus on writing appeal letters for denied claims-after all, having a denial in hand is a great impetus to action. However, if billing is done correctly, appeals should be rare. The bigger problem lies beneath the surface of unpaid claims, and here's how to follow up on those lost and unpaid claims:

Start with an insurance aging report. If your system allows it, select only claims older than 45 days, because anything newer may be either in the adjudication process or the payment could be in the mail.

Prioritize your work. Act on claims that are nearest their timely filing limit first, and act on large claim amounts before doing small claims. Just in case your biller cannot complete the follow-up, you shouldn't forfeit reimbursement to a missed timely filing limit, and if your biller runs out of time, it's better to let the small claims slide than lose payment on the big dollar claims.

Check your claims acknowledgment files. If you use a clearinghouse or submit directly to carriers, you may be able to check on an individual claim manually. Often electronic feedback that a claim had a problem is sent to you automatically. Sadly, most billing software is unaware of these claim acknowledgment files, and many billers simply ignore the files that are available. Some medical billing companies use sophisticated custom software to parse acknowledgment files daily so that they can act to identify and correct a problem claim as quickly as possible.

Make the call. If the clearinghouse or acknowledgment files don't provide the reason a claim has not been processed, it's time to call the insurance carrier. If the response is, "we have no such claim on file," your biller should verify both the mailing and electronic addresses for the claim. Otherwise, find out what went wrong, and ask as many question as it takes to fully understand what needs to change to get the claim processed. Simple fixes can often be made over the phone and the claim can be sent back for reprocessing. Other fixes may require more work. You might even find out that the claim was paid to another provider or a lost check needs to be reissued.

All of this takes time and the right personnel. Think of follow-up as an investment, and the payoff will be the difference between a practice that's just doing okay and one that's truly profitable.

How to Choose the Best Medical Billing Service CMS Announces "Meaningful Use" Rules Medical Billing And Coding Service - Reasons To Pick As Your Career Option How Under-Coding Affects the Financial Well-Being of Your Medical Practice Important Difference in UK Vs US Health Insurance Models TV Medical Leads

A Dozen Steps to Successfully Appeal Denied Claims

Appealing denied claims used to be a simple process. A biller working with a physician's office would stamp "APPEAL" in big red letters on a photocopy of the claim, and mail it back to the insurance company. These days, you'd be wise to put the cost of that postage in the bank, and throw away both the APPEAL stamp and its red ink stamp pad. This sort of knee-jerk response won't even make it past the insurance company's initial computer screening; they'll likely toss such "appeals" into the trash and you'll never hear anything back from them.

To successfully appeal denied claims, you need to get your "A-game" on; otherwise, you won't see a penny for your efforts.

Follow these steps to effectively appeal denied claims.

1. Recognize denials. Insurance companies don't print the word "denied" in big letters across the top of the claim form. In fact, the word "denied" may never appear at all. The insurance company simply declares the reimbursement amount to be "$0" and enters an adjustment reason code next to the amount paid. The key is to identify it as separate and distinct from a contractual adjustment, which is - and should be - a write off.

2. Understand why the claim was denied. Before you pick up the phone and demand to speak to the claims representative, determine the root cause of the denial. You can't effectively appeal until you know why payment for the service was denied. In addition to the reason code, there is a remark code. Look up the insurance company's definition of that code to get details about the reason for the denial. WPC maintains a complete listing of standard reason and remark codes, available on their website.

3. Don't procrastinate. There is often a timeframe in which you can resubmit a claim after it's been denied. Pull the record, research the code, call the patient, etc., but don't delay: most insurers only allow a few months to resubmit a claim for reconsideration.

4. Follow the insurance company's rules. Each insurer has an appeal process. The Centers for Medicare and Medicaid Services (CMS), for example, has a form to complete when appealing the denial of a Medicare claim called the "Medicare Redetermination Request Form". Get familiar with the insurer's protocols to understand your options if your first appeal is turned down. Don't give up; most insurers have multiple levels of appeals and even a grievance process if you disagree with the outcome after you've exhausted the appeals process.

5. Make a compelling case. An appeal means that you disagree with the insurance company's decision, so put your debate cap on and gather supportive evidence to present your case. Perhaps the most important aspect of your claims letter is the content. The letter should go well beyond stating, "please pay my doctor." Build a compelling case for why the claim should be paid:

Develop a professional letter that begins by referencing the claim number, date of service and patient; then, briefly describe the particulars of the service in question. Use the insurer's own language if possible. For example, to appeal a claim denied because the insurance company claims the treatment was experimental, quote from the insurer's own marketing materials where it declares it seeks to provide the best medical care for its beneficiaries. When the insurer questions the necessity or separate payment for a distinct service, the physician should type or dictate a paragraph or two about the benefits of the service to the patient. Seek objective evidence to support your case from your specialty society and medical literature. Look to see if Medicare or Medicaid pays for the service; if they do, you can argue that even the government has determined that payment is appropriate. Copy and attach sections that support your case from coding manuals, including past issues of the American Medical Association (AMA) CPT Coding Assistant, a periodical that the AMA publishes to clarify CPT codes. For appeals that concern clinical issues (for example, medical necessity), send the appeal to the medical director of the insurance company. Look at the class action settlements between several large physician organizations and a number of national insurance companies; review those settlements to see if anything in there can support your position. See the HMO Settlements site for up-to-date compilation of the settlements, as well as a list of pending lawsuits.

6. Confirm receipt. Don't just send the appeal and hope for the best. Review your submission online, or call the insurance company to confirm that they received your appeal, noting the name of the operator, extension number, date and time. Place a tickler in your practice management system or Microsoft Outlook to follow up in 30 days.

7. Set boundaries. Although it might make you feel better to fight for every dollar, it doesn't pay to prepare a third-level appeal of a $2.41 service, particularly if you only perform it once a year. Establish protocols for dollar thresholds that you'll appeal only once, twice, etc.

8. Don't go overboard. Avoid fighting for a claim that should have never been submitted in the first place, such as an undocumented service. Your physician may have provided the service and feels there should be some way to get paid, but - as the saying goes - if it wasn't documented, it wasn't done.

9. Carbon copy stakeholders. Your appeal to reverse a denial is a matter between you and the insurance company, but sometimes pulling in other key stakeholders helps. Your first, and most important, advocate is the patient. Although patients may never be held responsible for payment if a denial is ultimately upheld, news of payment disputes certainly get their attention. And the patient's attention is just want you want. Prompting the patient to contact the insurance company directly to encourage payment doesn't guarantee payment, but it certainly helps.

10. Develop supportive language in your contract. Your contract establishes the relationship between you and the insurance company. Even though the insurer is the party that typically presents the contract to physicians for their signature, it's every bit as much your physician's contract as it is the insurer's. Proactively negotiate the inclusion of language that supports your efforts to appeal claims. If you're frustrated by the appeals process itself or if you keep running into certain problems, such as unfair bundling denials, seek to include clearer definitions of these processes in the contract.

11. Compile appeals. Appealing claims one-by-one may get the results you need, but it is laborious. If you've seen the same service denied for the same reason multiple times - or your insurer hasn't paid in a timely manner, according to your state's prompt payment law - compile your appeals and present them together for reconsideration.

12. Maintain a hassle folder for each insurance company. Keep a record of denied claims - by dollar and type. Measure and compare the data on a quarterly basis. If you negotiated a good reimbursement rate with an insurer, but all of your claims get denied, the "good" rate is meaningless. It pays to maintain a record of reimbursements and denials in order to effectively review your contract for its strategic contribution to the practice's bottom line.

Preventing denied claims is a key skill of successful billers. But getting some denials will always be a fact of life in today's complicated physician payment system. Appealing denials is your right: it pays to exercise it.

Tips For Improving Productivity in Your Billing Process

Apart from the patients, billing is the lifeline of the medical office. Whether your medical office's billing is done in-house or you've outsourced it to a medical billing company, there are specific things you should do that are crucial in maintaining a smooth billing process.

• Train the front desk staff. It is imperative that staff at the front desk has some type of introductory insurance and/or billing training. Make certain your staff is verifying insurance benefits prior to patients' appointments. Be sure to train new employees on the various types of health insurance; indemnity plans, HMOs, PPOs, and POS plans. Educate the front desk on authorizations and referrals. Explain the difference between 'Original Medicare', 'Medicare Advantage', and 'Medigap' in order for the correct co-payment/co-insurance to be collected and the correct health insurance cards to be copied for billing purposes.

• A thoroughly completed patient registration form is crucial in the billing process. Nothing frustrates a medical biller more than a missing insured's date of birth, a suffix missing from a Medicare HIC number, or a missing home phone number. Train your front desk staff to keep a watchful eye on the registration form to make certain all fields are completed! This tip not only helps with initial claims submission, but also assists in future collection procedures.

• A biller and only a biller! If your billing is done in-house, your billing should be designated to specific person/persons whose only job is billing. When the same person who is manning the front desk, putting patients in rooms, and answering all telephone calls is also the employee who is doing your billing-mistakes are bound to happen. These mistakes may be the very reason a provider will make the decision to outsource the practice's billing.

• Using a web-based application is especially helpful in improving billing productivity because it allows the provider and billing service to stay connected. For one thing, the medical office has access to patient accounts, which can be helpful in collecting outstanding patient balances during an encounter. On the other hand, the biller has real-time access to any patient demographics, diagnoses, insurance, or any other pertinent information needed to prepare claims for submission.

• Maintain your accounts receivable. Many a provider would be shocked if they knew the dollar amount in their 90+ column on their insurance aging report! Each state has prompt payment statutes which give the timeframe in which both paper and electronic claims are to be paid. If your billing is done in-house, take the time to ask your biller to print an A/R report. If you are unhappy with what you see, find out the exact problem. Is it that your biller does not have enough time to post charges, post payments, submit claims, and maintain the A/R by themselves? Are you the owner of a billing service whose billers are in charge of their own accounts for the entire life cycle of the claims? In either scenario, listen to your biller(s) and if they need help, hire a separate employee whose only job is maintaining the accounts receivable.

Medical Billing Services: Solution to All Your Billing Woes

With changing times there has been considerable change in the way professionals work and now there are specialists for everything. Growing scrutiny on part of the government has placed the onus of providing good quality services on the concerned professionals while maintain stringent standards. Medical profession is no exception to this changing trend. In the past doctors were concerned only about taking care of the patients and paid little attention towards maintaining the records and other paperwork. But with time, these matters have gained paramount importance and medics have to shoulder additional burden of taking care that such records are well maintained and error free. The cost of hiring staff for maintaining medical records and medical billing has gone up along with increased stress for the medics. That is where the professional medical billing services come in picture.

There are genuine companies for providing medical billing services to all sorts of medical professionals like physicians, surgeons, etc to spare them hassle of maintaining patient record and other related paperwork. All this is done electronically using latest software and stored in backup files too for safekeeping. The process is completely error free and safe from the any unauthorized person. Also you need not invest in extra staff and space while saving you lots of time and energy. Also the fee charged is very nominal and data remains protected from any damage by natural agents like fire, water, termites, etc.

Companies providing these world class medical billing services maintain the data and also deal with the matters concerning insurance etc. Most patients are covered by insurance and these companies make sure that claims are filed correctly and in given time frame to avoid any loss of revenue. With their systematic work, filing tax returns also become hassle free, correct and timely. These companies help in removing the additional stress on medics and let them concentrate completely on what they do best - treat their patients.

Managing Patient Balances in Trying Times

Patients don't like to pay medical bills, and a growing number simply don't pay. The trouble is, as the economy puts the pinch on everyone, more out-of-pocket burden gets shifted to the patient in the form of larger patient deductibles, coinsurance, and copays. As patient responsibility grows, so will your patient accounts receivable. Think of it as working for free.

Chances are, you do more pro bono work than you realize. Through inaction, your practice may allow patients who are perfectly able to pay, choose not to pay; yet you may continue to see those patients while their balances snowball. You can, however, protect your practice with the following four action items that will help you get and keep control of your patient A/R.

Identify patient's ability to pay up front.

Have your front desk ensure the patient understands that he or she will be responsible for any remainder balance as determined by their carrier. Don't allow the front desk to estimate or guess what that remainder might be, because it's impossible to know for sure when even the carriers refuse to provide a definite answer. Also, it's okay (emergencies excepted) to decline new patients who either have no insurance or have none with which you are contracted-it's your choice. However, steer clear of a reduced or sliding-scale fee schedule unless you and your attorney are willing to navigate the Medicare rules and commercial contracts mine fields.

Offer a payment plan.

When a patient either asks for payment arrangements or simply doesn't pay on the second statement you send, offer a payment plan to lower the payment hurdle. The best plans allow a reasonable-but not long-time to pay and expect a regular and realistic minimum monthly payment. Use a plan such as 4 equal payments for balances up to $300, 6 equal payments for balances $301-$800, and up to 12 equal payments over $801. You can apply your own breakpoints, but keep the minimum payment above $50-about the cost of a month of cable TV service-to keep the cost of billing less than the revenue. Likewise, extending payments beyond 12 months just puts you in the free banking business.

Create a delinquent payment policy and collection plan.

When it's time to send a second statement, your odds of getting paid have seriously dropped, and you have to hope that the patient may have overlooked the first bill. Attach a gentle reminder or stamp the second statement "Past Due." By the third statement, you have identified a patient who either cannot afford to pay or chooses not to pay. That's when a letter with your signature needs to accompany the statement. The letter should be clear, concise, and friendly. It should express concern, inquire if there is a problem, invite a call to discuss a payment arrangement, and tell them the next collection step if your billing office does not hear from them. If you get no response from the letter, or if someone on a payment plan misses a payment, sending more statements will be fruitless. Write off the account as "bad debt," turn it over to a collection agency, and don't wait to do it. If you keep the account on your books, you're only kidding yourself, and you will never have an accurate picture of your A/R. Past-due balances do not age well, and though a collection agency may cost you 35 to 50 percent of the balance due, acting quickly can reduce your chances of getting zero, nothing, nada, zilch.

Develop a patient discharge policy.

Providing some level of pro bono medical care is, of course, a good thing. But shouldn't you decide who gets your valuable time for free? Patients who choose not to pay are stealing that choice from you. It should be your choice to operate a thriving practice or run a free clinic. For this few, but growing, number of patients, you have only two options: Either adopt them or discharge them.

Discharging a patient from your practice should be done with a carefully written letter (be sure to check with your attorney) that explains the circumstance and offers emergency-only care for, say, 30 days. Again, we're talking about patients who have chosen not to pay. It's not an easy decision to make that final discharge decision, but a discharge is the last line of defense in protecting the health and future of your practice.

Employee and Employer Concerns

Employee or labor Unions have long been a concern for various firms. These groups have been formed by the workers in order for them to unite and attain the same goals. Better working environment and in-discrimination has always been the subject of discussion. As this matter worsen in time, employers have come up with many solutions just to pacify their employees.

For instance, workers compensation in California has already mandated that all workers from day one of employment needs to be protected through medical insurance, disability insurance and life insurance. These types of insurance policies have arisen due to the frequent assemblies of the many different labor union groups discussing on how to make the workplace a safer place. The Worker liability insurance policy secures the employees well being by compensating and shouldering the medical expenses if by any means they are injured while on the job. If the employee should stop working because of the injury, he will then receive reimbursement insurance wherein portions of his salary are refunded.

The hostile work environment definition can include the smallest of what some may call a practical joke or the serious verbal and physical harassment. But mostly it is all about discrimination according to age, sex, race, disability and religion.

In some cases, even the smallest or absence of these alleged hostilities are used by past, present and probable employees to bring the employers to court. To protect the firm along with its officers and directors, employment practices insurance has been acquired by companies against these lawsuits.

These are just some of the many concerns of both the employees and the employers. If they will just compromise then the workplace will be a happy and safe place for one to be at.

Sunday, December 9, 2012

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