Overcoming Challenges in Medical Billing - The Appeals Process

Appeals are a normal part of the medical billing process, but that doesn't make them less frustrating or time-consuming. There are steps you can take, however, to make the appeals process much smoother and more profitable for your practice.

First, take a bird's eye view and review your most commonly denied claims, prioritizing both for volume and dollar value. You want to use this information to focus your attention where it's going to benefit your practice the most. You should also know the cost of appealing claims-that will help you prioritize those claims that will net the most for your practice and will also help everyone in your office understand the importance of eliminating denials before they occur whenever possible.

Be sure your appeals process also addresses priority by payer deadlines:

Prioritize by shortest deadlines, then by largest amount due. Draft and distribute a list of payer deadlines to insure your appeals are filed in a timely manner.

Next, develop a standard process for addressing the most common denials that represent the most revenue for your practice:

Develop a letter template that can be quickly generated and sent for each appeal. Consider designating specific staff members to handle particular denials so that they can develop expertise in that area and learn to expedite the appeals. Make sure your staff is cross-trained so that denials aren't delayed by a staff member's absence.

Each appeal letter should include key information:

Patient name and demographics, insurance account numbers and employer information Date of service The CPT and ICD-9 codes A short, clear explanation of what you are appealing (denial, underpayment) and why (explain medical necessity, authorization received, etc.)

Use your template or a checklist to ensure you include all of this key information-it's easy to leave an item off in the rush of the business day. Make sure you scan supporting materials so that you can easily find and attach them to the appeal letter.

Of course, one of the key steps in the process is to evaluate your most common denials so that you can eliminate them before they occur, as mentioned above. You will want to evaluate your report of most commonly denied claims to make sure you are addressing root causes and avoid the need to appeal to begin with.

In most medical billing software packages, you can generate denial management reports that group your denials and rejections by reason and dollar amount, trended over time. This helps you identify frequently recurring denials and rejections that can be addressed through process changes in your practice. For example, if you're routinely receiving denials because the patient is ineligible for insurance coverage, then you may want to begin verifying each patient's insurance eligibility prior to scheduling appointments.

But regardless of how you do it, spend time organizing your claims appeal efforts to insure you:

Eliminate root causes of denials wherever possible. Prioritize your appeals to insure you are pursuing the highest dollar return. Standardize your process so that it is as efficient as possible.

These steps will enable you to improve the productivity and profitability of your appeal processes, your medical billing, and ultimately your practice or billing service.

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Huge Medicine Bills? Choose the Cost Effective Part D Plan

Suppose, Greg counts his annual drug cost for the regular medicines which comes out to be $9200. Greg decides to sign up for a Medicare Part D Program in which offers low premium, no deduction and no coverage in Donut Hole period. The working for a plan if the annual drug cost is too high and the total drug cost calculation can be understood with reference to the following Example:

Costing chat for Greg will be: • As there is no deductible cost, Greg pays 25% of the total cost of $2830 [amount set for entering coverage gap for the year 2010]. This means in this level Greg pays $708.

• Now, Greg enters the Donut Hole period. Here he will have to pay the 100% amount for the drugs till he reaches $4550 [Amount to be paid to exit coverage gap for the year 2010]. As Greg already made a payment of $708. So, to exit the gap, he will have to pay another $3842

• By the time Greg exits the Donut Hole period, the total amount of $6672 is already paid by Greg and the Insurance Company [$2830 before entering donut hole and $3842 during the donut hole]. So the remaining cost of $2528 is still to be paid. But Greg is now entitled to pay only the 5% of the remaining cost only and the rest will be paid by the insurance company i.e. Greg pays only $126.40 more.

As we know, without the Medicare plan Greg was to pay $9200. But, using the Medicare Part D Plan, Greg pays: $708 + $3842 + $126.40 = $4676.40 and the fixed low premium every month for the plan. So, you can easily figure it out that how cost efficient is using Medicare Part D plan. You can make the calculations easily and check out what amount wills you have to pay for the Part D plan and how cost effective will it be for you.

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Medical Insurance For a Secured Future

Increasing cost of medical treatment is creating a lot of problems for consumers. Every year, salaried people have to spend a large part of their salary on medical bills. According to a recent survey, medical bills are the biggest reason behind the bad credit history of people. Medical expenses have touched the sky and keep on increasing day by day.

It is no longer for an ordinary citizen to afford normal medical expenses. Nowadays, maximum people prefer to go with medical insurance to eliminate the risk of huge expenses up to a certain extent. These insurance programs provide almost complete coverage regarding the health problems. By adopting the health insurance, you make sure that none of family member will face any problem at time of health disorder.

Even though the market of this kind of insurance is quiet big in United Kingdom and there is a huge demand of such services. Still few people do not feel comfortable to buy medical insurance programs, as they find the premium quiet expensive. But, it does not mean that all companies offer the same program with same premium amount. It is huge market where you can find good number of companies with different kind of policies. Individuals can purchase the policy as per their need, requirement and pocket. It is advisable to choose the cost-effective policy providing the maximum coverage for your health. In current scenario, absence of health insurance policies can be a biggest mistake of your life. It is not something which can be ignored easily.

Absence of medical insurance simply means that you will be in great financial trouble at a time of emergency. By taking insurance policies, you not only cover yourself but also save your family from any future disaster. These programs help you a lot at time of medical emergency. You are not required to spend even a single penny from the pocket. At time of emergency, individual needs to choose the nearest hospital and get admitted as soon as possible. These insurance companies takes care all of your expenses and medical bills.

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How to Start a Home Based Medical Billing Company

If you have decided that starting a home based medical billing company is the best move for you, you are approaching a great opportunity to cash in on a high demand market. With physicians finding it harder and harder to collect on invoices, they need medical billing companies that are able to efficiently manage their billing and ensure that there is appropriate payment and claims filing for the revenues to be generated more effectively. There are some insurance companies that can send physicians for the ride of their life, and there are some medical programs that make it quite difficult and timely to collect payments. Most of this has to do with the billing process, and that is why you can be a very beneficial asset to many health care facilities and physicians in your community or service area.

Why Home Based?

A home based medical billing company is a great option for those that have daily lives, but still wish to enter the workforce with a strong head. There are more and more businesses these days going into internet based servicing and medical billing is a great industry for that move. Not only are most of the billing processed completed through computer software, but there is no need for excessive costs on building space if you aren't going to be seeing any clients or managing staff. You can definitely hire staff that works through a network, giving you an efficient team at less than half of the cost.

All the Necessary Software and Hardware

You want to get all your materials and tools together when starting a home based medical billing company. As the company is home based, you definitely want to have the appropriate communication portals open, whether through web conferencing, phone conferencing, or any other method that uses today's technology to avoid the need for physical presence. You will also need many other tools such as:

• Appropriate billing and invoice forms • Fax and printer • Appropriate accounting software • Business licensure and registration

Having the right tools and materials will ensure that you are able to adequately perform the functions of the medical billing profession through your own home based medical billing company. Physicians will count on you to provide a steady cash flow, and with a home based company, you can provide this function for only a fraction of the costs of regular medical billing companies.

No matter which way you look at it, having an office is just an added expense that could be done without. With the great technology of the internet, you don't have to be bound by an office building that increases your service charges and causes your clients to pay for it in the services the obtain from you. You want to provide the most cost-efficient services which is possible by cutting your own costs and taking your business to the comfort of your own home, where you are known for your best ideas anyway.

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Medical Billing Outsourcing Empowers Doctors & Levels the Playing Field Against Insurance Companies

Insurance companies are definitely in a stronger position in the 'payer payee' relationship shared with healthcare providers. They have the advantages of scale, power and a large claims database. The complexity of billing procedures further tips the scales towards them. Technology and the internet come to the aid of medical providers through medical billing networks, promising to level the playing field between the two players.

Insurance carriers benefit from complex medical billing process. Changing codes, rules, and procedures make filing claims tortuous and error-prone. Insurance companies pick on these errors to reject claims. Sometimes this happens repeatedly till the medical provider caves in and forgoes the claim. Medical practitioners lose out on a significant chunk of revenue because of this tactic.

Common tactics used by insurance companies to delay payments

Insurance companies take advantage of the intricacies of billing procedures. Some of the common strategies used by them to delay payments of medical claims are:

Picking out bureaucratic errors to reject claims

Most medical practitioners do not have efficient and reliable billing processes. Insurance companies pick out errors and omissions in the submitted claims to reject them. Almost 20% of medical claims go unpaid as a result of claim rejections and unaggressive follow-up. This cut in revenue can seriously setback the operations of a medical practice.

Low allowable amount

Insurance companies take advantage of their large size by concurring on low allowable amounts to medical practitioners. Medical providers are left with little choice but to go with the low sums of money as competing insurance companies also offer the same amount.

Post-payment refunds

Insurance firms conduct post-payment audits to correct mistaken payments and redeem them. They have access to a vast claims database and can verify records to demand post-payment refunds. This further depletes the revenue of medical practitioners.

Insurance companies have an efficient billing system that allows them to reduce payments to healthcare providers. The added advantage of scale makes them a tough proposition.

Medical billing networks reinforce the medical billing process

Medical billing networks consolidate the claims database of various healthcare practitioners. Medical billing service providers provide the means to facilitate this network. The information of clients is combined into an efficient and accountable automated system that also offers effective records management and efficient processes. Medical providers can leverage the economies of scale to their advantage, as insurance providers have been doing since years.

Advantage of medical billing networks

Independent medical practices cannot do much on their own, but collectively they can build an effective system to combat the obstacles in getting payments from insurance payers. Billing networks enable medical providers to do business with large-scale insurance companies on an equal footing. The networks offer the advantages of improved collections, effective revenue management, lower audit risk and added revenue sources.

All medical practices should use medical billing network services to combat large-scale insurance company tactics to deny and reject claims. Healthcare providers can use network services to maximize revenue and streamline revenue management processes.

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How Good is Your Claims Scrubber?

The best way to reduce outstanding receivables in a medical provider's office is to make sure that claims being sent out are clean. Clean claims require less effort in collecting payment and result in faster payments. Claims with errors come back as denials and then need to be corrected, resulting in a delay in payment for services, and possibly no payment at all. After all, 42% of denied claims are never appealed or corrected.

Most provider offices do not have the time or the manpower to take care of denials in a timely fashion and it is one of the largest sources of lost money in a medical office. Sending out clean claims results in over 90% being paid on the first submission, leaving less than 10% of claims to be denied. By eliminating the avoidable errors, the real issues can be addressed and less money will be lost. One good way to ensure clean claims is by having a good claim scrubber in place. Many billers do not even know what a claims scrubber is but it actually influences your receivables in a huge way.

A good scrubber analyzes the data that is on the claim and compares the data to its rules engine before the claim is submitted. There are several levels of scrubbing and good claim scrubbers will analyze data on many levels. The most basic scrubbing function is to make sure that all required data is present. For example, it will check to make sure a name, valid date of birth, insurance information and id number are present. It will also verify that there is a date of service and a procedure and diagnosis code. But it may not verify if the data is accurate. For example, a basic scrubber may not notice if a date of service entered was mistyped and is for an obviously incorrect date, such as 04/01/2001. To a biller it is obvious that the entry person made a typo, but a basic scrubber may not catch this.

Another example is if an invalid insurance identification number is entered. Medicare identification numbers are a social security number followed by a letter, sometimes also followed by another number. If the person entering the claims makes a mistake and misses one number, a basic scrubber may not notice. But a good claim scrubber would pick up that there were only eight digits instead of nine, giving the user a warning that the claim may have an error.

Today claim scrubbers come with many more capabilities. They not only verify required data is present, but they also analyze icd-9 and cpt codes. They use rules from CMS and other major insurance carriers to detect mismatches and invalid combinations. Warnings will be given if data does not appear to meet carrier guidelines.

Now with web based software the claim scrubbers have improved even more. With the use of data mining a claim scrubber can build on its own knowledge base by continually reevaluating the adjudication rules of different payers. The claim scrubber is constantly improving its own quality of scrubbing capabilities. With this type of scrubbing capability a provider can reduce the percentage of human error and greatly improve the number of clean claims submitted.

Most practice management software systems with electronic claims capabilities come with some form of a claim scrubber. It is important to know how complete the claim scrubber that you are utilizing is. A good claim scrubber can have a huge effect on the accounts receivable of an office.

When we switched from a server based practice management system to a web based system we found that the claims scrubber on the web based Xena Health system caught up to 50% more errors that would have caused denials. The claims scrubber on our old system would have allowed those errors through creating much more work on the back end.

Some of the features in a product like the Xena Health's inbuilt claims scrubber include

• Required field checks • Required format checks • ICD-9 checks and specificity • E & V code checks • CPT validity • HCPCS validity • The CMS Correct Coding initiative • Local and national coverage determinations where appropriate • Payer specific requirements

Copyright 2010 - Alice Scott - Solutions Medical Billing Inc

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Advantages of Outsourcing Your Practice's Medical Billing

When it comes to medical billing, many doctors feel lost and defeated. It seems that a lot of those who are in the medical profession have given up all hope of handling the financial aspect of their practice, settling instead to become inefficient and ineffective in the overall management of their career. If you're a doctor and feel dissatisfied with the way your practice is going, then perhaps you should consider outsourcing your billing and practice management needs.

This may come as a surprise but your medical practice can still become more cost-effective. To achieve this, there are easy steps you need to take, the first and most important of which is to hire the services of a firm that is an expert in medical billing. A medical billing firm offers a number of advantages (and you'll find out what these as you read the succeeding paragraphs).

Lower Overhead Costs and Paperwork

First and foremost, when you decide to go with medical billing outsourcing, you'll be given the chance to cut down your costs. Outsourcing billing firms have a variety of solutions that aim to lower your overhead as well as reduce the amount of paperwork your office still has to deal with, leaving you free to attend to your patients' needs, which are of course the most important aspect of your profession.

Enjoy Faster Transactions

Outsourcing medical billing firms also make use of electronic processes for claim submissions, allowing you to enjoy faster transactions. This means outsourcing your medical billing can bring you expediency as far as revenue generation is concerned, with claims paid within a period of seven to 14 days and errors reduced by automatic checking.

Promote Your Practice

Outsourcing can really do a lot of improvements for your medical practice. More effective and efficient medical billing is not the only advantage you can enjoy. Your trusted staff can turn to other matters such as the promotion of your practice for the recruitment of new patients, the provision of competitive healthcare to all your patients, the development of marketing strategies, and the maintenance of strong patient relations.

Eliminate Employee Expenses

Finally, outsourcing your medical billing can help lower your employee expenses. You won't have to allot salaries for in-house employees tasked to handle your billing issues, and you won't have to provide insurances. Everyone knows that the medical practice is one of the most difficult and most expensive. With all the advantages offered by billing outsourcing, no doubt your practice will become bigger and better - without the unnecessary expenses.

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Boost Collecting Timely Patient Payments in a Medical Practice

So many times a medical practice provides good patient service, but fails to collect payment for services rendered. It appears that there may be some underlying reasons why payment is not collected and it is prudent to explore why.

Collecting Begins With Policy

You may post signs in your practice regarding your policy to collect, but adhering to a policy is the most important key to collecting revenue. Make sure you have written collection policies and that employees are aware of your collection procedures. There can be no excuse for not collecting especially if the policy is well known within the practice. Train employees to collect and how to address situations where payment is unlikely such as patients with no cash or checkbook.

It is best to train patients on your collection practices prior to the appointment so that they come prepared to pay for their portion of the services. Make it accepted procedure to patients that you will be collecting at the time of service. Copays and coinsurance payments must be paid at the visit. Some offices will not see patients if they are not prepared to pay for their part of the service cost at the appointment time. Whatever your medical practice collection policy is, be sure to inform your patients in advance.

Beliefs About Collecting Payments From Patients

There may be beliefs in your medical practice held by employees, management or even physicians that you are providing a service to individuals that is needed that may not be afforded. Make no mistake that healthcare services or any service that is provided is worthy of payment. Explore beliefs with employees or providers who may not deem collecting as important or necessary. Remember that collecting after the visit is always much harder than at the time when the patient is there with the ability to provide payment of some kind.

Beliefs that may be limiting in some way are worth discovery and scrutiny for they can cause a person to act in a way that is counterproductive without knowing it. Ask employees or physicians what the belief is behind not wanting to collect. There may be good reason, but most likely it will lead to a limiting belief of some kind that they hold. Limiting beliefs can hinder the practice's means to collect revenue on several levels.

What You Resists Persists

Have you ever heard of this saying? It means that when something is in direct contrast to your desire you will resist it and it will consistently plague you until you can break free of the resistance and let the flow happen. Money flow in your practice cannot happen as long as you are resisting the process. Allow the money to flow to you. If you are providing worthy service then patients will happily pay for that service. Expect that you will collect revenue timely and efficiently and it will begin to flow. Get the medical practice employees on board with this decision and with a team effort you will see more abundance in your practice.

Your Vision Is Key

If you see your medical practice as ineffective and small, then that is how it will be. Get a vision that is productive, abundant and flourishing. Focus on that vision and implement strategies, one at a time, to support the vision that you hold for your practice. Even in this fluctuating economy there are physician practices that are thriving. Yours can be one of those remarkable success stories.

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On the Value of Medical Care

A horse, a horse, my Kingdom for a horse - William Shakespeare, Richard III

In this famous, semi-comical passage, Shakespeare says more about the economics of healthcare than all of the textbooks ever written. The ironic truth King Richard articulates is that value of something fluctuates dramatically with circumstances. When life itself is at stake, something of prior enormous cost can instantaneously be rendered worthless(his kingdom), while something inexpensive becomes priceless(a horse).

This discontinuous type of valuation may be unique to medicine. For example, for a healthy person, the local trauma surgeon has no economic utility. However, once in an accident, that same surgeon is of infinite value, and the transition can occur within seconds. After the surgery, the calculation reverts back to baseline.

One could argue that large portions of the medical care practiced in the country is worthless. Most of the time, money and effort spent on doctor visits and testing done on healthy people does little but reassure. However, the occasional discovery of a treatable problem is of immense benefit.

The closest analogy I can make is national defense. In times of peace, a standing army is a huge waste of manpower and money, but if a war arises quickly, it's invaluable.

Items like cars, food, clothing, gold and stocks do not have this type of economic discontinuity. Their value fluctuates, but does not rapidly alternate between zero and infinity. Economists, politicians, and healthcare administrators do not understand these concepts. Much physician discomfort with outsiders attempts to control medical care stems from a poorly articulated appreciation of the difficulties expressed here. The fact that disease is frequently random, unpredictable and unpreventable adds to the confusion. It appears we will need an entirely new way to think about the value of healthcare, much like the difference between classical physics and quantum mechanics. I will pursue some of the themes here in future blogs.

I will be hiking in the Sierra for the next few days, and won't be posting.

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Medical Billings

Those who are looking for jobs in the field related to the medical billing process should be very vigilant when making their selections as many may end up landing into fraudulent situations. There are several ads printed in the national and international newspapers both well circulated and the sparsely read, which make tall claims of lucrative offers for the professionals of the medical billing. The ads even have blaring toll-free numbers which are provided to affirm the company's existence, in cases the people want to get information about it.

In most of the cases the scams related to the medical billing cost significant amount of money, as the people are only interested in selfish motives and have no concern about helping out others. It has been witnessed that when those seeking out for lucrative business opportunities opt for medical billing business, they have to face scams at various levels. Sometimes they are cheated by providing obsoleted database, at other times it is outdated software and yet, at other times, the programs tend to be unauthorized or illegal. For the people who have concerns about scam there are certain steps to be followed.

Even if a person has a slightest doubt of being a victim to scam they should seek out the company and confront them. Make sure to record the conversation and the correspondences when communicating with the counter party and firmly ask them for resolving the issue or paying back the money invested. In the cases, it does not seem to work, seek help from the law enforcement officials after giving the counter party a notification. Sometimes the scammers may offer lucrative offers to the customers in their ads or when a person calls them on the toll free number.

They would ask the potential customers to make decisions and would do their best to make the customer buy the package they are selling which may be the different medical billing courses or other services courses on immediate basis, while offering some added feature, which will not be offered later. Beware of this trap, never commit to any purchase prior to doing a thorough research about the same, in case of the courses being offered make sure that they are accredit through the regulating bodies, as they cost several hundred dollars depending on the level of the degree.

To avoid the traps set by the scammers in the field of medical processing, select the firms which allow you to conduct a thorough research about their validity and has no problem in talking to their existing or previous clientele. Make sure to ask these clients if the company provided them with the same level of opportunities of making money as it promised.

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Medical Billings New 5010 HIPPA Version

The new changes for Medical Billing that are taking place in 2012. There is always learning to do in this field and sometimes we don't have all the answers.

The newest changes to impact Medical Billing is the implementation of the version 5010. As we rang in the new year we rang in new laws, January 1, 2012 marks the deadline for the new version of the HIPAA transactions. The version 4010 has been in use since 2003 and the Centers for Medicare and Medicaid Services (CMS) are requiring all HIPAA covered entities, which includes physicians who conduct any of the transactions named in HIPAA electronically (i.e. claims or remittance advice), to begin using Version 5010 starting on January 1, 2012.

We had been getting emails about this as well as Medicare and other websites reminding providers and staff of this upcoming change. Nevertheless, there are always going to be those not quite ready for the change. Many providers have yet to upgrade their billing management software. I do not need to upgrade mine and those that use an outside clearinghouse should not have to upgrade theirs. It can be very costly unless you have ongoing continued monthly software support which is often times includes any new releases and updates that have come out.

The CMS which is the federal agency overseeing this compliance has agreed to not levy any punishments for a few months giving more providers more time to get ready. Most providers who send claims directly to Medicare are the ones that need to start testing if not already done; not to mention now, having to submit a transition plan. Other options if not interested or unable to afford a software upgrade is, signing up with a clearinghouse or Medical billing service to transmit your claims for you. This option should be considered if a software upgrade becomes to costly. Given hard times and the constant reimbursement reduction threats, not all providers can afford it and remain in private practice.

If you are currently with a clearinghouse and your remittance address is a post office box be sure to talk to your clearinghouse or Billing service as those will not be accepted with this new version. You must register the POB with the clearinghouse so remittances will continue to go through to that POB but on the claim, forms reflect the physical address. This can and will delay the claims being sent or processed until confirmation is received that registration in completed.

This should help everyone to understand a little better this newest change. There are still more to come.

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Chiropractic PreAuthorization Blues

More and more we are seeing insurance companies require pre authorization for chiropractic services that in years past did NOT require such. If the doctor is out of network, then many companies will require pre authorization in order to make collecting insurance payment more difficult and force the doctor to consider going in network with the insurance company.

Many Billing Services have experienced going through the hoops, making the call and ordering the Care Notification in full compliance with the insurance plan requirements and STILL do not received the full payments due. Here is an example:

United Health Care. Most of our providers are out of network with United Health Care because the payment fee schedule is so much better than if the doctor is in network, and this is even after the higher copays and deductibles.

We are running into more and more plans that will state the insurance verification thus: If you get your Care Notification prior to providing the services, the insurance plan will cover 70% of the eligible expenses. IF you do NOT get the required Care Notification, then your insurance coverage will drop to 50% of the allowed eligible expenses.

I have talked with many Chiropractic Offices and Billing Services who tell me that they do not even bother to get the required Pre Authorization or Care Notification. They do not want to be bothered with the extra administrative details. However, they are also letting the insurance companies get away with keeping 10% to 20% of each claim. Depending on how much the doctor bills, that can be worth $10.00 per claim, and when you multiply that by how many doctors are out of network, you can bet the extra fee adds up to a tidy sum of the DOCTOR's money - money that the insurance company is keeping.

Since it is the Billing Service's job to get the absolute highest pay for the doctor, one always takes that extra step and gets the required Care Notification.

This entails reporting the diagnosis codes, plus stating how long we need treatment, how many sessions are required, and lastly, exactly what codes will be billed.

Well now, how does ANYONE know exactly what treatment is necessary on the first visit? How do we know how well the patient will respond to any type of treatment?

So, to cover our bases, we report the diagnosis codes, and then we ask for the time allotment that covers until the end of the year (or whenever the plan benefits expire). We then request the exact number of session covered that year by the plan. If they allow what we ask for, then I will not have to call them back this year for a fresh Care Notification (Pre Authorization).

Some case managers will only allow a fraction of what we ask for, and we all know why that is: So the Billing Service or Doctor's Office will be required to take this extra step more than once this year. Again, hoping to discourage us from going though the hoops necessary for getting that extra 20% that is our due.

The Billing Service goes through these hoops, and even after being in full compliance of the Pre Authorization/Care Notification requirements, the claims will INVARIABLY come back paying only the 50%!

Here is how to handle it: Call the insurance company, speak with the representative in India, and send the claim back to be processed correctly. Then, in about four weeks we receive a form letter from UHC stating that the claims were processed correctly and no further payment is due.

Next step is to appeal on paper. This means: paper, ink, time preparing the appeal, envelope, stamp, frustration and having to spend money on a massage (Or a drink). Sometimes the appeal works, and sometimes it doesn't.

We have spent months appealing for such claims, going back and forth ad infinitum, with no real results. Our last recourse is to send the whole thing to the Insurance Commission.

Our new modis operandi is to skip the step where we call our friendly insurance representative in India and simply go straight for the appeal on paper.

This Billing Service stands upon Principle, and if the claim is worth as little as $10.00, if we are in the right, we take these situations all the way to the Insurance Commission.

Sometimes it pays, sometimes it doesn't. The point here is that the insurance company counts on the doctor and his staff to NOT follow up on these situations, and thus they will realize a higher profit margin, AT THE EXPENSE OF THE DOCTOR.

It is bad business for the insurance companies to require pre authoriztion to begin with, and it is double bad business to make the doctor fight for monies due AFTER the doctor has complied with all of their little nit picky requirements.

EVERY Billing Service and EVERY doctor in the US of A should be appealing all the way up to the state Insurance Commission on all such claims. Otherwise, the insurance companies will not only continue to demand pre authorizations, but will tighten the rules and regulations even more.

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Insurance Denial Received - Now What?

When you receive a denial panic is the first inclination. You start pulling out your hair or pacing the last resort is yelling. Now it is time to take slow deep breaths to calm yourself and lower your blood pressure.

You take a deep breath and call the phone number on the insurance denial paper.

Your called is answered by a customer service representative who reads in the computer for your date of service, the name of the medical provider, and the place of service treatment was provided. The customer service can only parrot the answer that is on the computer screen a duplicate of what you now hold in your hand. Call is ended your blood pressure is rising once again.

You start reading the denial and on the back it tells you to appeal. It gives an address and usually an address to mail it.

What is needed for an appeal?

1. Why was it denied?

This answer must be addressed especially if you feel it was wrong. Remember you are only appealing the date of service in question, the place of service, and the medical provider.

2. Get your medical records. You can get them from your medical provider or hospital. If an ambulance or laboratory test or x-ray were involved get it from that medical provider.

3. Write a letter. The appeal letter must be precise. If written it must be legible. If typed make it as professional as possible.

4. Mail the letter (Please sign it) to the address for the appeal process only. Try to get a specific name and get it in by the time allotted.

5. Send it certified, registered in other words make sure it was signed for. This is your insurance that it was received and on time.

Medical insurance companies make it a practice to deny your claims. That is there job. They do not want to pay your bills if they can avoid it.

Thank you for reading my article. Please feel free to read any of the various articles on numerous subjects.

Linda E. Meckler Copyright 2010

Medical Coding Specialist - How to Become   Things to Know About Medical Billing Programs   Avoiding "The Tempest" of Investigation   Insurance Coverage for Mental Health Issues   

Officials Delay Red Flag Rules Until December 31, 2010

The Red Flag Rules were initially intended to be enforced starting June 1, 2010 but members of Congress decided in a press release issued on May 28th, 2010 to have the Federal Trade Commission (FTC) announce that it would delay enforcement of the Red Flag Rules until December 31, 2010.

Although this was communicated by the FTC on May 28th, 2010, it is recommended that your practice be forewarned as enforcement on these rules could still start before the end of the calendar year.

The reason for Congresses delay is due to the fact they requested another delay in the enforcement timeline because they are still working on the legislation to limit the rules and regulations surrounding the Red Flag Rules. Based on information released by the FTC, "a limited further delay of the rules area justified so that the FTC does not begin to enforce a regulation that Congress plans to over-rule." It is essential to know though that the FTC has stated it will start enforcement before the end of the calendar year if Congress passes a law with an earlier effective date.

The House of Representatives unanimously passed H.R. 3763 on October 20, 2009, which is a bill that would automatically relieve physician practices with 20 or less employees from the Red Flag Rules and allow other practices to request an exemption from the FTC. The bill was introduced to the Senate Committee on Banking, Housing and Urban Affairs on October 21, 2009 but the Senate did not introduce the bill until May 25th, 2010, and no one has voted on it.

The Red Flag Rules requires all creditors, or those who provide goods and or services and allow customers to pay later (i.e. an example is when a medical practice renders service, files the claim and then finds out the patient has not met their deductible and therefore the patient is responsible for that particular date of service and billed accordingly) to implement an Identity Theft Prevention Program. The intentions of the rules are to protect consumers from identify theft by requiring businesses to show they can protect sensitive financial and personal data. Under this definition, the FTC considers most physician practices to be creditors and therefore expects them to implement the necessary procedures and processes to comply with the Red Flag Rules regardless of when they are implemented.

Medical Coding Specialist - How to Become   Things to Know About Medical Billing Programs   Avoiding "The Tempest" of Investigation   Medical Billing Advocacy Services Expand Focus to Attorneys, Businesses, and Physician Practices   Courses For Medical Insurance Coding   

Medical Record Coding Co-Payments

Medical record coding is a category which is related to the calculation for specific insurance policies. The co-payments made by the patient can be decided by the biller after applying the medical record coding.

Health information-certified professionals are fully capable of extending their duties to the tricky calculation which involves impeccable health insurance policy knowledge. The biller must acquire the relevant policy's terms and conditions in order to fully apply their expertise to the summation of costs.

Reimbursement and denial of reimbursement are two widely-focused topics which have subsequence importance for the billers where co-payment is involved.

The technicians are responsible for completing the patient's chart and personal health information. First the health information is separated by the category of diagnosis and treatment basis. Then, there is specific computer software which is used for the data storage for the distinctive categories.

The grouping of data is stored within the database or institutional computer system, for documentation purposes. It is crucial that the health documentation to be accurately completed and managed according to procedure.

Be wary of the common mistake when data storage is involved. Save a back up copy of the input in a separate disk or database in a different hardware. Other than that, understand the release of information for hospitals and other health institutions. The officers at the hospital must be able to retain the confidentiality of the clientele data. These are proof of excellent judgment in character.

This information must be managed in proper order so that it can be reviewed later by other health consultant. Examples of the data stored in the list are health history, observations, diagnoses, treatment outcomes and surgical interventions. It is important for the patient to have a proof of documentation regarding his or her health history in order to collate data when the occasion calls for it.

Medical Coding Specialist - How to Become   Things to Know About Medical Billing Programs   Avoiding "The Tempest" of Investigation   Medical Billing Advocacy Services Expand Focus to Attorneys, Businesses, and Physician Practices   Insurance Coverage for Mental Health Issues