Medical Claim Billing

The process of medical claim billing involves first converting medical data into standard medical codes which are then submitted as a bill consisting of those codes to the relevant insurance companies who then pay the claim using pre-agreed payments for particular combinations of codes.

The job of medical billing is considered a sub-area of medical coding as the information in the medical bills is sent in the form of these standard medical codes. These professions are great career choices right now due to the rising percentage of elderly people in the populations of western world countries. The number of jobs in these areas is rising significantly faster than the average.

The interaction between the medical billing of claims and the insurance company paying for those claims is not always straightforward or simple. There are often disagreements about how much can be claimed for and other sources of error in the process. Some insurance companies still process claims using a paper-based system instead of doing things electronically, which leads to additional errors as well as considerable delays.

One method of helping get claims processed quickly and effectively is to submit the bills via a clearing house instead of directly. This reduces the amount of errors and speeds up the process.

There is now a company given the task of finding errors in medical claims. Large numbers of errors are found, mostly concerning over payment. The fact that the company involved gets paid according to the amount of money it recovers by correcting errors is controversial for obvious reasons.

Most medical claims are currently submitted electronically, mostly using specialist software. Ability to use this software is one of the areas medical billing employees are trained in.

Medical claim billing is a vital part of any healthcare business, and a good career choice currently.

Medical Classification is Medical Coding

What is medical classification and what is medical coding? Well, both the terms refer to the process of transforming details of medical diagnostic processes and diagnosis into medical code numbers that are universal. The four basic categories of coding are diagnostic codes, procedural codes, pharmaceutical codes, and topographical codes. The diagnostic codes are used to group and identify diseases, disorders, symptoms, and medical signs, and the procedure codes are numbers or alphanumeric codes used to identify specific health interventions that are taken by medical professionals. While the pharmaceutical codes are about medications the topographical codes indicate the concerned body part.

From where are all these details about the patient's disease and his medical history taken? Some of the sources include,

Doctor's notes Biochemistry Lab reports Radiology reports

What is the use of these medical codes? They are used to track diseases and quite useful for health insurance companies, government hospitals, worker's compensation carriers etc. These medical coding/ classification system applications are mainly used for reimbursements of the medical bills from insurance companies. It is also used for statistical analysis, in epidemic surveillance and for knowledge based decision support.

Here are the different types of medical classifications;

Reference Classifications International Statistical Classification of Diseases and Related Health International Classification of Functioning, Disability, and Health International Classification of Health Interventions International Classification of Primary Care International Classification of External Causes of Injury Anatomical Therapeutic Chemical Classification System Technical aids for persons with disabilities: Classification and terminology International Classification of Diseases for Oncology, Third Edition ICD-10 for Mental and Behavioral Disorder Application of the International Classification of Diseases to Dentistry and Stomatology Application of the International Classification of Diseases to Neurology International Classification of Functioning, Disability and Health for Children and Youth Procedure Coding System Diagnostic and Statistical Manual of Mental Disorders Systematized Nomenclature of Medicine TNM Classification of Malignant Tumours Unified Medical Language System Mendelian inheritance in Man Current Procedural Terminology Health Care Procedure Coding System North American Nursing Diagnosis Associates Logical Observation Identifiers Names and Codes International Classification of Headache Disorders 2nd Edition This article has been viewed

Medical Billing And The PPO Plan

Medical billing is the process of collecting fees for medical services. A medical bill is also called as a claim that has to be collected from the insurance company. There are different types of insurance plans. What is the PPO plan? PPO is a term used in health insurance that stands for Preferred Provider Organizations. It is a managed care organization of medical doctors, hospitals, and other health care providers who are associated with an insurer agent/administrator's clients to provide health care at reduced rates. It is today one of the most preferred kind of health care plan in the country. A preferred provider organization is sometimes also referred to as a participating provider organization.

More than 50% of the insured population in the US have chosen to go for the PPO plan. Its popularity is mainly because of the fact that in this system, doctors / hospitals have made an agreement with the insurance companies to offer discounted fees to the company's members.

The primary advantages of going for the PPO insurance plan are,

Its not mandatory to maintain a primary care physician

Can directly see a specialist without referral

Freedom to choose own doctor / hospital

The main advantage of going for a PPO plan is that one can choose a health service provider from outside the provider list Another less popular system is called an (EPO) exclusive provider organization (EPO), wherein if you seek care from a non-preferred provider there is no coverage at all. One must remember that with freedom to choose will always mean more expensive medical bills.

There are many types of PPO plans and the actual benefits depend on different factors like,

Monthly premium amount

The amount of coinsurance obliged to pay,

Whether treatment from the network/ outside

Annual deductible amount

What are the other features of a preferred provider organization? They generally include services of review of the patient records by the company representatives to ensure that there is no foul play. In the case of non-emergency admissions, an approval is taken from the insurer in advance.

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The Definition of Medical Malpractice

Medical malpractice has become a greater concern for doctors over the years. The age of lawsuits means that people are quick to sue for any wrongs they feel have been committed against them. While most doctors do everything they can to avoid being sued for malpractice, sometimes there is just nothing they can do. Even when they do everything right, something can still go wrong - and the doctor often takes the blame for these problems, whether they were responsible or not. Unfortunately, it is very simple for someone to bring a lawsuit against another person today, but on the bright side there is a complex process which rules out most frivolous suits.

The definition of medical malpractice is the deviation by a medical professional from the standards of the medical industry, thus causing injury or death to a patient. True medical malpractice is rare, but lawsuits for medical malpractice are not very rare. Successful malpractice suits must follow the definition of medical malpractice in that they prove that the doctor, through action or inaction, caused wrongful injury to a patient. Typically, this means that a practitioner grossly violated the standards set by the medical industry.

Because of the presence of medical malpractice lawsuits, medical professionals are required to maintain personal liability insurance to protect them and offset the costs of malpractice suits. However, in keeping with the definition of medical malpractice, the lawsuit must prove that the medical professional violated medical standards. This requires an expert to prove that there was a violation of standards. With medicine becoming more and more advanced, there are more things that can go wrong. This means that malpractice suits can take advantage of the legal aspects of medicine not being caught up with the practice.

As new medical practices continue to push the envelope, people will seek reasons to sue when things go wrong, but the definition of medical malpractice protects doctors from many lawsuits filed by people who are just looking to put the blame somewhere. Fortunately for doctors who are concerned about wrongful lawsuits, there has been a recent push to reform many of the torts which govern the medical industry. They are intended to eliminate lawsuits filed by people who, for whatever reason, feel they were wronged by their doctors.

There have been numerous high profile lawsuits against doctors who were said to have violated the definition of medical malpractice, but the fact is that these expensive lawsuits negatively impact the ability of the medical industry to offer quality care when they are brought about by people who are simply seeking money. With the new reforms that are being put into place, it is likely that frivolous lawsuits will begin to decline. As it is, they are on the rise and have been for quite some time. If something is not done to stop wrongful medical malpractice suits, the medical industry will continue to be inhibited in its ability to provide quality care at reasonable cost.

Medical Office Manager Tips

Medical office managers greatly contribute to a smoothly operating office. Various strategies are used by a medical office manager to stream line processes so that doctors can provide comprehensive healthcare effectively. If you're looking to make a career in medical office management, you need to be well aware of all the things that will help you perform this job with utmost effectiveness. Before stepping into the office, here are some medical office manager tips that can prove to be helpful to you.

You must know all the functions of the office

As a medical office manager, you must have a firm grasp of all the processes that happen at the office. These functions could include coding of medical records, making appointments for patients and scheduling surgeries. Understanding the individual functions of the medical office will enable you to segregate the various functions into job descriptions.

Offer training and cross training for the various job descriptions

Now that you've identified the various office functions and separated them into job descriptions, you can start offering the training needed to perform these functions. While training one staff member to perform one task, offer training for a different task as well. This is a wise thing to do. For example, if a certain employee calls in sick or is unavailable for some other reason you can mobilize other members of the staff to perform the function appointed to the missing team member. In other words, cross training gives you back up for other job descriptions.

Use software for financial management

This could be one of the best medical office manager tips you could ever get. Financial management is going to be a major aspect of your job. There are a lot of numbers you're going to have to deal with in this line of work. For instance, the medical practice will have building operations, staff salaries, insurance for medical malpractice, general liability insurance and even utilities.

You will have to manage costs for medical supplies, medications, telephones and other office devices like faxes and copiers. Medical practice rests on two pillars. Using software to manage all these functions greatly reduces the burden on your shoulders and speeds up the financial management process. There are software packages that are not only precise but they are also efficient. On the financial management front, you will oversee accounting and budgeting functions while the physician will deliver healthcare.

Make sure the employees have the right credentials

You need to make sure that all the employees have the appropriate medical licenses and certifications so that agency fines, penalties and lawsuits related to malpractice can be avoided. Keep an eye on the renewal status of employee credentials. You can easily do this by maintaining a detailed list that features employee credentials with expiration dates. You should preserve copies of all employee certifications so that they can be quickly accessed and easily verified.

By internalizing these medical office manager tips, your job will not only be convenient for you, but it will also prove to be beneficial for the staff and the doctor.

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Medical Billing and Coding Job Description, Training and Salary

If you've been thinking about taking some medical coding or medical billing classes online or getting medical coding or billing training you want to make sure you understand what this career and the job entails and have a good idea what kind of salary you'll make. Of course you may want to open a work from home business and it's certainly possible but may require a good education and training and an entrepreneurial ability to do so.

Going into a home business is not for everybody and getting on the job experience first is a good idea unless you have extensive education and feel like you completely understand the billing business.

Medical billing means you would be documenting patients' visits to a doctor, clinic or hospital or other type of health facility. Medical billers, assistants or Specialists enter clinic and patient information into expensive billing or practice management software so you can submit medical claims to health insurance companies. You would also be posting payments from insurance carriers and patients and run off management reports. You may also be required to make follow up calls.

Medical billing doesn't have to be done in a doctor's office. You can do billing from home, any office, clinic or hospital, billing service or facility that has the necessary software. Many doctors outsource their billing and may choose a home based business if the service is competitive in terms of cost. Or they may choose a smaller service and not necessarily one of the large billing services. So cost is a factor.

Medical coding is a totally separate function and not a part of the medical billing business. Medical coding cannot be done from home or outsourced to a service. Medical coders usually work right in the doctor's or clinic's office doing the coding before it is sent on to the billing service. Coder's salaries are comparable to medical biller's salaries.

So if you decide to get medical billing training you don't have to worry about coding and vice versa. People usually choose one or the other. Medical billing is more popular and offers more versatility since you can work from home in either your own business or for a doctor or clinic that allows you to do that.

Billing services often have graveyard shifts and may run around the clock. Salaries to start out run at least $10 an hour and up depending on your training, education and or experience, or related experience. You can move up fast as you gain the experience on the job and can command a much higher salary for the experience you're getting both from the clinic, practice or company you're working for when and if you leave for another medical billing job.

You don't need national certification, for example, as a billing specialist but it may help you get your foot in the door faster. There is money available for both your local on-campus and online medical billing training too. Make sure to check out online schools thoroughly to avoid any scams.

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Medical Billing Job Description and Salary Range

If you've been thinking about entering the field of medical billing I'm sure you're wondering what exactly a medical biller does and what salary you can expect. There is a lot of interest in this field and many ways to enter it. Although experience is best it takes getting a job in that field to get experience and it can be a vicious circle. But first the job description. Keep in mind that depending on the facility you may or may not be doing all of the following. And if you work for a billing service your job may be quite different since it is not a medical facility.

If you work as a medical biller or a certified Medical Billing Specialist you will compile and track outstanding balances that are owed to medical clinics, medical offices or other medical facilities. You would maintain the records of payment for all patients for that medical facility. You would make payment arrangements with the patient and collect on any past due accounts.

As a medical biller, medical billing assistant, billing clerk or billing specialist you would have access to a lot of confidential medical information. You would be working with collection agencies and even the courts to collect on delinquent accounts. You may also be working with lawyers and others on the estates of patients who have passed away on resolving their unpaid accounts. You would be working and coordinating the deductions from payroll for the employees of your clinic or facility. You'll be aware of the rules and regulations you must follow to be in compliance with any local, state or federal laws or regulations.

Now what skill should you have? You'll be working with a lot of numbers and technology. You want to be comfortable using a computer, software and office equipment. You'll be learning billing software if you haven't learned it in medical billing training. You don't need to learn coding as that is a separate function and coding is usually done before it reaches the biller, but some knowledge of it can only help. You will want to have good communication skills as you may be talking to people about their medical bills.

The salary you can expect will depend on previous experience and medical billing training you have had. You will make a higher salary as a certified Medical Billing Specialist which requires taking a national exam. But generally your range will be in the $31,000 to $45,000 range. The more experience the higher the pay generally. There are lots of ways to get experience and training including medical billing training online and at your local college. There is plenty of money and financial aid available for online courses and you want to check out every school thoroughly to avoid any scams.

Medical Billing - How Bad Are Things Really?

Everybody hears about how the medical billing industry is robbing us blind. Medical costs are out of control, or at least so they say. Medical billing software, just to be able to run your medical billing practice, costs an arm and a leg. Medical billing agencies like Medicare and Medicaid, Blue Cross, Blue Shield and even private insurance companies are ripping us off left and right. Nobody wants to pay claims, or at least that's the perception. But what's the reality? Does anybody who is doing the complaining really know? Medical billing statistics are posted all over the place, especially with the Internet being so filled with information. But does anybody really take the time to look up the stats to see how bad things really are?

For example. Did you know that it costs between $8 and $10 to process the average medical claim? Now maybe if you're charging a procedure that costs thousands of dollars, that's not such a big deal. But what if you're putting in a claim for a $50 walker. That's almost 20% of the total cost of the item, which is absolutely absurd. So yes, in this case, costs are crazy. And the problem is very simple. To process a claim, the same procedure must be followed, regardless of what the service being billed is. If the walker could be processed at a cheaper cost, no problem. But that is just not the reality of it.

Forgetting about claim processing costs, what about salaries? Well, for the fortune 500 company like Prudential, paying a salary of $35,000 a year for a claims processor is not such a big deal. But when you're talking about a non profit organization like Medicare, which is actually running in the red and in danger of shutting its doors, paying these people that same $35,000 a year is insane. But they have to. Why? Because if they don't, where do you think they're going to go? To the private sector of course. So salaries must be competitive.

What about turnaround time for claims. Yes, we all complain that our claims take forever to get paid. But what we don't understand is that the people who are really getting killed are not the patients, because they will eventually have their claims paid, but the billing companies. Turnaround time for paper claims can be anywhere from 30 to 90 days or more and this really puts a strain on a company and its cash flow. So as bad as the patient may be having it, the medical billing company is suffering big time.

When you add all this to the cost of just starting a medical billing agency, you can see that the industry itself is behind the 8 ball before it even begins. Throw into this mix doctors who back in the 60s charged $15 for a doctors visit, now charge anywhere from $50 to $100 for a visit and what you end up having are costs that are totally out of control.

This is a spiral that is most likely to continue until people can no longer afford to get sick.

Medical Transcriptionist Salary

Medical transcriptionists' salaries fluctuate considerably. There is no fixed income for work of this kind, with earnings depending on the productivity and skill of the medical transcriptionist.

In 2002, the American Association for Medical Transcription (AAMT) conducted a survey, where an average annual salary of a little over $31,000 for the medical transcriptionist was reported. The highest-earning 10% of those surveyed had a salary nearing $18 per hour; the lowest-earning 10% earned a touch over $9 per hour. Of course, some earn distinctly more and some considerably less than that figure. All said and done, a medical transcriptionist's salary is situational. Sometimes it takes much more than mere skill. It helps the medical transcriptionist to be at the right place at the right time.

On average, a qualified medical transcriptionist can earn about $50,000 for full-time work and $20,000 if he is working part-time. Transcriptionists can bring in a greater salary if they have their own business or are prepared to work from home.

A really skilled medical transcriptionist can earn $25.00 - $35.00 per hour. The money in this field is substantial. More importantly, it can be a priceless add-on to your already existing income and career.

Medical transcriptionists are compensated in various ways. Some get their salaries based on the number of lines transcribed or hours worked. Others have a per-hour basic pay with bonuses for additional production. It is important to remember that independent contractors have a greater salary than transcriptionists working for others. However, working independently is fraught with drawbacks. The expenses are greater; they receive no or meager benefits, and there is no real security in the job.

Medical Billing Salary Range

Although medical billing career may not earn a very high pay like other medical related jobs, medical billers do bring home a salary that is enough to live a fairly comfortable life.

Medical billing salary is influenced by lots of factors. The training gained in the billing field accounts for the major part. The person who completed a relevant course in the medical field, gains special skills and knowledge and this is a clear indication that he/she is putting extra efforts in order to perform a good job as a medical billing specialist. Depending on the education qualification, the hourly rate varies from $12-$15. Another most important factor that affects billing pay is how long someone has worked in the field. Medical specialist with experience of 1 year earns around $12 per hour. Those who have more experience in billing earn up to $16 per hour. However, the geographic location also plays a role in pay scale. For instance, areas where cost of living is high, the pay will be more. Billers who work in New York City, Houston, Chicago and California are able to pull a good amount of salary. Work locations such as hospital, billing company or private practice will also affect the salary. Since there are lots of factors which affect the salary of billing, it is really not easy to predict the pay scale. Studies have shown that 50% of people earned around $35,000-$45,000 annually.

Medical transacting can be a work at home opportunity, which can fetch a descent salary in a comfortable home environment. Most of the medical billers are paid hourly, rather than annually. While biller who is experienced can earn around $40,000 a year as an independent contractor working from home, a billing and coding specialist who runs his own firm can earn $100,000 a year. However, people who are searching for home based job should be very careful. There is lots of fraud going on in this field. These scammers charge hundred to thousand dollars and in exchange they claim they will help to get a placement in billing. They also promise that medical billing job can earn a substantial amount of money and no experience required. But in reality, those who paid to get a job end up with no job, no money. Billing is a very competitive field, so without experience or training in medical billing field, it is almost impossible to get a job.

The best way to get a good salary is get trained, have few years of experience, and by doing justice to the job. A medical billing professional with all these qualities will definitely earn a good salary.

Medical Insurance Billing and Coding Explained

Medicine is an art, a science and a business. Doctors learn the artistic and scientific aspects of their profession in medical school. But the business aspect of their practice - getting paid - requires a completely different set of skills - skills most doctors have neither the time nor the interest to acquire. Even if they did, few doctors would have to time to handle the complex administrative aspects of a modern medical office. Enter Medical Insurance Billing and Coding.

Medical Insurance Billing and Coding specialists work in doctors' offices, clinics and other medical facilities. Their primary job is to submit claims to insurance companies to ensure doctors and support staff are properly reimbursed for the services they render. Medical Billing and Coding professionals tend to deal mostly with private insurance companies and the agencies of state and federal governments who pay medical claims, e.g. Medicare. The Medical Billing department is often also responsible for collecting co-payments or deductible amounts from patients directly.

Processing a Claim

To process claims, the Medical Insurance Billing and Coding specialist first deals with the patient's medical record, which contains the physician's notes on what services were performed. The specialist must then translate this information into a five-digit numerical code drawn from the American Medical Association's Current Procedural Terminology (CPT) guide. The actual diagnosis is also coded based on a government guide called the International Statistical Classification of Disease and Related Health Problems (ICD). It is very important that the CPT and ICD codes match up, or a claim will likely be rejected.

In fact, according to the Healthcare Billing and Management Association, up to one half of all medical claims are initially rejected by insurance carriers. Medical Insurance Billing and Coding specialists must therefore need to learn how to skillfully adjust and resubmit claims in a way insurance companies are more likely to accept.

Paper vs. E-Claims

In the past, virtually all medical billing and coding was done on paper, which was slow, inefficient and expensive. Today, more and more claims are being filed electronically, although paper-based billing is still very common. In the coming years, computer skills will be increasingly important to Medical Insurance Billing and Coding professionals.

Training & Certification

To become a Medical Insurance Billing and Coding professional, one should take a specialized training program in this field from a recognized and accredited college or university. Such programs can normally be completed in about a year. After that, industry certification is also recommended. The Certified Medical Reimbursement Specialist (CMRS) accreditation by the American Medical Billing Association is one of the most recognized of specialized certification in this field.

Medical Insurance Billing and Coding is a highly specialized field that is critical to the operation of modern medical offices. The need for well-trained Medical Insurance Billing and Coding specialists is likely to grow significantly as America's population - and the need for quality medical care - grows over the next few decades.

Medical Billing and Coding Job Requirements and Salary

If you're thinking about entering the medical billing or medical coding field you'll be glad to know that there is a strong demand for qualified, experienced medical billers and medical coders. I discovered that medical coding first came into being because there was a need to standardize and organize all the new technologies and medical and surgical procedures. So much new information has surfaced over the years that improved medical billing and coding techniques were necessary.

Insurance companies and health care providers needed these codes to help classify claims. Because of this need for better coding and billing practices, the demand for billers and coders increased. This has made billing and coding jobs the fastest growing area in health care.

Besides working for large billing services, there is a huge need in insurance companies, large clinics, doctor's offices and other healthcare facilities. These companies are looking for experienced and educated people. Making mistakes in billing can cause a lot of problems legally. So usually they prefer that an individual has experience or good medical billing training.

There are no state requirements for certification. You can take one national certification exam to get a certificate in medical billing as a Specialist but it's not a state requirement. The organizations that offer the exams are not state or federal organizations. Medical coding also has no state requirements for certification.

Although on occasion an employer may hire someone with no experience, it's possible that if you have related experience they may decide to hire and train you using their expensive software. But generally they would like you to have some experience or medical coding or medical billing training through a college, university, trade school or online school.

Can you get a job in coding or billing? This is a copy of the wording in a classified ad in our local newspaper today to give you an idea of what to expect. Make sure to check all your local newspapers and surrounding newspapers to see what's stated in the ads. Here it is: "Medical Billing Specialist, full time, permanent position, Monday through Friday, flexible hours, requires insurance/Medicare billing experience. Electronic billing required. Long term care experience helpful. Basic computer skills required. Competitive salary. Submit resume."

Ads can vary in many ways. You can call these companies and find out a lot of information too about future hiring and if they ever have any other medical billing or coding jobs that don't require as much experience or education.

Medical coders with little experience may start out their career at $9 to $10 an hour and work up to $35 to $45 an hour. You can see it won't take long to get experience and your value as an employee will be rewarded with a higher hourly rate. Once you have this experience you'll be able to move into other companies at a higher salary. But there is much more to know about how to get your training online or offline and how to get it cheap and avoid scams. Federal money is available for online classes too.

Medical Insurance Claims Editing - What Does it Mean to Scrub an ...

During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It's unfortunately a necessary evil, as physicians who contract with insurance companies rely on that reimbursement as the lifeblood for practice survival.

Receiving payment from insurance payers involves submitting claims after providing treatment. Whether it's in an office setting, emergency room, or an operating room, filing a claim involves supplying the appropriate procedure and diagnosis codes along with any appropriate modifiers pertaining to the treatment performed. However, simply filing a claim does not assure that it will in fact be paid.

The policies of insurance companies for accepting or rejecting claims change often. A claim that got paid last month may be currently denied without notice depending on carrier specific modifications. This results in a large batch of denied claims for physicians performing many of the same procedures. Not only is it confusing for a practice to attempt following up on these adjustments, it can result in lengthy days in accounts receivables along with rollercoaster collection periods.

Is there a secret weapon physicians can use to assist with streamlining claims to maximize acceptance? That's where claim "scrubbing" enters the picture. The term "scrubbing" refers to an intricate cleaning of a claim prior to submission. Over the past 10 years, automated claims editing has been developed which helps to validate that a claim is appropriate and accurate for submission.

There are two components in scrubbing claims. As the most common error for denied claims is data entry errors, the patient demographic data is reviewed for the most common mistakes. For instance, keying in an incorrect procedure code that is age specific would make the claim invalid, and the scrubber flags those types of errors for correction prior to submission. This is the easy part of the automation.

The complicated portion of scrubbing involves a thorough review of the codes and modifiers to ensure complicity with carrier specific guidelines. This is commonly referred

to as the "rules engine." In some fashion, every data element of the claim is analyzed. If a physician submits a claim for a hysterectomy and the scrubber sees a male gender it will obviously be flagged. The scrubber verifies that a procedure performed is associated with a diagnosis code that justifies the medical necessity of that procedure along with variables such as gender, age, date and place of service and any required modifiers.

The complexity of scrubbing should not be underestimated. By the time one multiplies the total number of Medicare local and national coverage determinations, along with data from the Correct Coding Initiative (CCI), ICD-9 codes, and modifiers the potential numbers of editable combinations surpasses ten million. Advanced claim scrubbers, though, can review about ten claims per second.

By including national and local coverage determinations from all of the Medicare geographical regions in every state along with data from the Correct Coding Initiative (CCI), approximately 35% of existing CPT codes are represented as a baseline in claims editing programs. There is no Medicare medical necessity guidelines for the remaining 65% of codes, therefore claim scrubber software companies hire clinicians and nurses who work full time evaluating up to the minute medical necessity data posted by insurance carriers around the country on their website as mandated by law. In addition, procedure codes are matched with all feasible diagnosis codes that are believed to be clinically defensible for claim acceptance. As one might expect, this is a costly endeavor so most claim scrubbing software companies license this portion from the few companies performing the research.

So how good are existing claim scrubbers? There's a wide range available, either as a standalone product or integrated with practice management software. Often the billing company utilized will incorporate a scrubber. The best ones will routinely achieve over 95% claim acceptance on the first pass. Practices who were previously performing manual edits typically find that after instituting the technology the scrubber flags over 30% of claims. This means about 30% potential claim denial prior to scrubbing, which drags out the revenue cycle. By having the scrubber flagging problem claims, changes can then be made instantly prior to submission, rather than waiting weeks for a denial. As a result, the practice will see more reimbursement and receive those funds faster. There will also be less back-end work secondary to denied claims.

Can relying on an experienced coder achieve the same acceptance rate? In all likelihood, no. As mentioned, scrubbers check demographic information along with the codes. Also, if a payer changes a filing guideline on its claim form or a medical necessity requirement, a certified coder would probably not be aware of it in a timely fashion. If a physician is contracted with a large amount of carriers, the chances of being subjected to rejected claims increases dramatically without a way of continually monitoring these myriad and often complex requirements.

Embracing an advanced claim scrubber, whether directly or indirectly, will allow one's practice to effectively combat the convoluted world of insurance claim rules and regulations. Practices that incorporate claim scrubbing rarely move away from the process. When the bottom line receives a significant boost along with peace of mind from knowing the latest technology is in their back pocket, why would they?

David L. Greene, MD is National Sales Director for Superior Medical Billing.

He can be reached at dgreene@superiormedical.info and (866) 989-8918 ext 320.

The website is [http://www.superiormedicalsolutions.com]

Superior Medical Billing is a Full Service medical insurance reimbursement company providing services spanning the entire revenue cycle from A to Z. The company utilizes top notch technology with first rate customer service.

If you would like to collect more money at your practice and faster, Superior Medical can help you achieve that goal. On average, practices collect 20% more and it's collected 33% faster within 6 months of going live. In this day and age of stagnant reimbursement and economic recession, wouldn't you like to collect more and not work any harder?

Medical Billing Training and Support Technology - Three Key Components

By Yuval Lirov Yuval Lirov
Level: Platinum

Yuval Lirov, PhD, author of Medical Billing Networks and Processes - Profitable and Compliant Revenue Cycle Management in the Internet Age (Affinity Billing), Practicing Profitability ...

As medical billing system complexity and functionality grow in step with growing number of users, the number of training hours per month grows by two orders of magnitude, as a product of increasing training frequency and increasing number of training hours required for each user. The development or billing managers, who must juggle training and support in addition to their main responsibilities, reach a point of over-extension, where none of the responsibilities are delivered well enough. A new, better scalable training and support approach is needed to meet the additional requirements.

The typical scaling up path for training and support includes a three-pronged approach:

Introduction of formal training and support tracking systems,FAQ analysis, andDevelopment of knowledge repositories aimed at reusing training and support expertise according to the results of the analysis stage.

First, a formal tracking mechanism for both training and support provides continuously updated information about frequently asked questions (FAQ), individual training and support workloads, response delays, and customer success in absorbing instruction. Predictably, the analysis of most frequently asked questions and answers often shows that a comprehensive and effective initial training eliminates a significant number of help requests. Moreover, customers can find answers up to eighty percent of FAQs immediately and directly by using some sort of a shared knowledge repository, e.g., wiki. Most billing companies using Vericle billing network, follow a two-step approach: first, they create a shared knowledge repository for instructional and support-related material, and second, they establish a training department, staffed with instructors who are able to develop a minimal set of training classes for various user categories (providers, front office managers, billers). The classes typically address various functional parts of the practice management system, such as Help system, Initial Patient Intake, Workbench, Scheduling, SOAP notes, Reporting, Billing, Personal Injury, Care Plans, etc.

The shared knowledge repository gradually accumulates educational mass, starting with frequently asked questions and answers, and with time adding videos of instructional sessions and various support email threads. The instructors move away from ad-hoc individual classes to a predetermined monthly schedule of live daily classes over the Internet (webinar format). In spite of the concern about diminished personal attention, subsequent surveys confirmed that majority of clients valued their own time more than personal handholding, and preferred the immediate automated response to a delayed personal conversation over the phone.

In summary, the increased scale of medical billing systems generates more sophisticated training and support requirements, which can be characterized as:

Training and support proximity: High - The separate training and client support departments converged as billers outside of the training department grew more comfortable with shared knowledge bases and began contributing instructional material and answers to FAQ;Degree of personal accountability and transparency: Significantly improved accountability and transparency generated important requirements and prepared the content for the next step; andEfficiency: High - The Internet infrastructure provides the minimal level of scalability that enables a single training session delivered remotely to handle an unlimited number of users, liberating the development and billing managers to focus on their own tasks.

Know any health care providers who complain about shrinking insurance payments and increasing audit risk? Help them learn winning Internet strategies for the modern payer-provider conflict by steering them to Vericle - Medical Billing Network and Practice Management Software, which powers such leading-edge billing services as Affinity Billing ( http://www.psychiatry-billing.com/ ) and Billing Dynamix ( http://www.pt-billing.com/ ), and is home for "Medical Billing Networks and Processes" book by Yuval Lirov, PhD and inventor of patents in artificial intelligence and computer security.

Medical Negligence FAQs

What is medical negligence?

Medical negligence occurs when a medical provider fails to exercise the kind of care and prudence that other providers in the same field of medicine provide. Medical negligence can occur in the form of recklessness, inattentiveness, or an omission. Common types of malpractice include misdiagnosis, failure to provide proper treatment of a patient's ailment, administration of the wrong medication, and the failure to inform the patient of the risks associated with a treatment or with information about alternative treatments. Tort law governs medical negligence. To establish that a provider's negligence was malpractice, a claimant must establish the following:

1. The healthcare provider owed a duty to the plaintiff;
2. The healthcare provider breached the duty;
3. The healthcare provider's breach caused the injury; and
4. The patient suffered damages because of the defendant's negligence.

Sometimes it is apparent that a medical provider's actions were the cause of a patient's injury. When this happens, a claimant can use the doctrine of res ipsa loquitur to establish negligence. Res ipsa loquitur means "the thing that speaks for itself." When the injury itself presents a reasonable basis for the inference that the medical provider breached the duty of care, a claimant may use this doctrine to establish fault. The claimant must prove the following to establish medical negligence using res ipsa loquitur:

1. The type of injury would not usually occur in the absence of negligence;
2. The instrumentality that caused the injury was in the sole control of the defendant; and
3. The plaintiff's conduct did not produce or contribute to the injury.

What is the "standard of care" for medical providers?

The "standard of care" for a medical provider is based on the kind of care and knowledge that a healthcare provider in the same field would exercise. Every person owes a duty to act as a reasonable and prudent person would, but a higher duty exists for healthcare providers. Medical providers have a special skill, and consequently, the law requires that they possess the same kind of knowledge and skill that a person in the same profession would exercise.

A court will likely find that a provider failed to meet the standard of care when he or she was unable to exercise the same kind of care as others in the same profession. A general practitioner is expected to act as a general practitioner would in the same geographic area and a specialist must possess the skills that a member of the specialty normally would have. A court will use medical experts in a particular field or experts with expertise with a procedure to establish the standard of care in medical negligence cases.

Who is liable for medical negligence?

Any type of medical provider, such as a doctor, nurse, or technician, can be liable for medical negligence. In addition to a medical provider, a hospital is sometimes liable under the doctrine of vicarious liability. Most of the time, another person is not legally responsible for the actions of others. However, sometimes an employer is liable for an employee's actions when the employee's actions occur during the course of employment. This means that even if the employer did not directly cause the injury, liability may attach when the employee was performing a job function. Consequently, a hospital may be liable for the actions of the medical providers it employs. In some circumstances, a court will hold a hospital liable for the actions of a healthcare provider it does not employ if the hospital led the patient to believe that the hospital employed the provider. This may occur in a situation where the medical provider was a contractor.

What is informed consent?

A healthcare provider must provide a patient with information about risks, benefits, and alternatives to a medical procedure or a type of medical treatment. This is called "informed consent." Informed consent is unnecessary in the following situations: in an emergency when the patient is unconscious or when a family member is unavailable to give consent. In these situations, a medical provider may perform a procedure without receiving consent from the patient or family members. The failure to give informed consent in other situations may amount to medical malpractice.

What kind of compensation is available for medical negligence?

Every state has regulations that determine the type of compensation a claimant may recover. Most states will allow a plaintiff to receive damages for past, present, and future medical treatment, lost wages, and pain and suffering. A court will determine noneconomic damages, such as pain and suffering, by evaluating the impact of the injury on the claimant's life. The embarrassment caused by the injury, the permanency of the injury, and the emotional distress are factors that determine the damage award.

Can a third party recover compensation for medical negligence under the doctrine of "subrogation"?

An insurance company or another party that pays for an injured person's medical treatment can recover compensation from the party responsible for the medical negligence. In effect, the third party inherits the rights of the injured claimant. Consequently, the third party can sue the healthcare provider and recover damages for the claimant's injuries.

What is the statute of limitations for medical negligence?

A statute of limitations governs how long a claimant has to file a legal claim for injuries caused by a defendant. As with all legal claims, every state has a statute of limitations for medical negligence. In general, a claimant has one to seven years to bring a lawsuit. The statute of limitations will typically begin to run when the injury occurred or when the claimant learned of the medical malpractice.

How To Get A Medical Assistant Certification

Medical assistants are the people who show you into a doctor's office, ask you for some basic information and enter it into the computer while you wait for the doctor. They also perform many other jobs, which depend on where they are employed. There is actually no requirement for these people to be certified, but 90 percent opt to get a medical assistant certification. This provides access to many more jobs, and assures people of their professionalism.

In order to get a medical assistant certificate, the person must graduate from a recognized program of study in the field. These are usually either certificate programs, though the certificate they give is a certificate of completion for the program, not a certification in the field, or two year degrees. They both provide coursework and a practical component where the student works in the field, usually without pay.

Medical assisting programs can be appealing short, some as short as 6-8 weeks. This generally appeals to students who desire to start work as close to immediately as possible. These programs are also available online, so many people who attend them simultaneously work at some other job.

After graduation from the program, or sometimes immediately before graduation, the student is eligible to take one of several certification exams in medical assisting. There are multiple agencies that grant certification, and some are more recognized than others. Deciding which certification will best suit them is for the student to decide, though the agency that offers their program of study should be willing to help.

Certification may not be open to students with felony records, even if they have completed a recognized program of study. Usually, the certification agency will consider the crime, how long it has been, and the student's recent conduct within the community in deciding whether to allow them to complete the exam.

The exam itself may vary, but the exam from the American Association of Medical Assistants (AAMA) is a 200-question multiple choice exam with breaks optional every 40 minutes of the 160 minute exam. The exam is computerized, and there is a tutorial option at the beginning for those who need it. The tutorial portion is not part of the time limit, and does not affect your score.

Assistants work in hospital, clinic and private settings. They perform a wide range of duties depending on what is needed from them, and the job markets for certified medical assistants is quite good. Growth is predicted within the industry in the next 10 years, so those with new medical assistant certification should have little trouble finding jobs.

Assistants may work long hours during the weekend or night if they work at a hospital or similar setting, but there are plenty of opportunities in doctors offices where the work may be 9 to 5 Monday through Friday. The job is not the best paid, but a living wage is made by most of those with certificates. It can be a very attractive job to those who want a steady paycheck and often, benefits, and who don't have a lot of other prospects, as well as a calling for people who feel drawn to the career.

Is Medical Transcription Necessary?

Medical transcription involves professionals transcribing the medical records as dictated by doctors and other medical experts. The information that is translated include clinical notes, consultation notes, psychiatric evaluations, lab reports and many others. The dictation is carried over a tape or voice files which are then sent to the transcribers. Since the medical field has a lot of terminology, the transcribers are required to have knowledge on these besides having great language and listening skills.

The transcribers are also known as medical language specialists and are responsible for assisting the surgeons as well as the physicians with the transcription. They are usually relied upon by the medical professionals to help in the effective and accurate communication of the medical information. Since there are a number of developments in the medical field, the medical language specialists are required to be up to with the current technology as well as new terminology.

Medical transcription is necessary because it saves the doctors and the medical practitioners the effort and time taken to write the report on their own. This is especially important because most hospitals require the maintenance of an extensive record for each patient. Transcription will ensure that the hospitals are able to get the records that are well written for storage and reference.

The process is also necessary especially in the wake of the changing technology. Since many people use these medicals records such as the physicians, insurance companies and hospitals throughout the world, it has become necessary to make them easily available and accessible. The introduction of electronic health records have necessitated the use of these services so that the records can be used for reference in different situations such as scientific research and insurance settlement among others. It is therefore important that the medical practitioners look for a transcription company that will produce quality transcripts. The companies should also have qualified, well trained and experienced staff that will provide the best services.

Medical Coding and Billing Specialist

Medical coding and billing is a field in healthcare industry, where an individual need not spend years learning in school and yet master his skills in it. You will find them in various healthcare settings such as: doctors' dispensaries, private or public hospitals, dental practices, pharmacies, laboratories, etc. Playing a significant part in the healthcare industry you will also find Medical coding and billing specialists running their own business. Medical coders ensure exact analysis of patient diagnosis as well as about its procedures whereas medical billers ensure that insurance agencies, providers of workers' compensation, Medicare and Medicaid timely receive patient reimbursement forms. You will find many of them skilled in both areas as medical coding and billing.

Medical coding
Also referred as medical analysis is a process where for medical procedures and diagnosis specify its universal codes in alphanumeric or numeric form. Medical coders refer to patient's medical record available in department, lab technology reports as well as doctor's report for determination of procedures and diagnosis to be coded. Coders track down details of injuries or diseases and procedures adopted for the treatment given to patients. Medical codes are used on reimbursement claim forms to be submitted to insurance agencies, on diagnostic request forms and Medicare and Medicaid for payment of claims. It is also used for internal facilities for healthcare service provider for the purpose of research as well as marketing.

Medical billing
Medical billing is a process handled by medical billing specialist who represents claims to health insurance agencies to confirm reimbursement to a patient for the services provided by a healthcare service provider. They also follow up and deal with problematic issues of patients on unpaid claims with insurance agencies, Medicare and Medicaid. Medical billing process remains same regardless of whether the insurance agency is privately owned or is owned by the government.

Qualifications of medical billing and coding specialist
In the healthcare industry the profession of medical coding and billing specialists is heavily in demand. Medical billing specialists with a Bachelor's degree in health information management or equivalent are placed higher at management positions, though they may not possess substantial practical knowledge or experience. You will also find the medical coding and billing specialists who possess a relevant diploma course or a certificate.

HIPAA
It is essential for a medical billing specialist to have detail knowledge and understanding of HIPPA an abbreviation of Health Insurance Portability and Accountability Act for which they also receive training. The act protects patient health information privacy whether it is in spoken, written or in electronic form and can adversely affect many levels working in the healthcare industry.

Medical Billing And Coding - What Are The Job Prospects And Salary ...

I know the job prospects and salaries for medical billing and coding professionals and medical insurance specialists are going to be good for many years to come. This is due to the demand for healthcare and the continuing need for specialists and professionals in these fields to ultimately help guarantee that reimbursements will be made in a timely manner.

Training in this field will never be wasted if you love the work and have many opportunities in your local area. If you have billing services, hospitals, insurance companies, large doctor's clinics and health facilities you'll likely have plenty of job opportunities. Of course you don't want to take this for granted and not only scour the paper for ads that appear to be in this field but make several phone calls to human resources departments in these facilities to find out what kinds of openings they have for medical billers, medical coders and medical insurance specialists.

Medical insurance specialists differ from billers and coders in that they are usually trained in both medical billing and coding. The job descriptions for billers and coders are quite different. You may enjoy billing work working with claims and patients or coding work - that is medical coding procedures or both.

When you're calling around on the phone you can also try to get an idea what the starting salaries will be for someone with education but no experience and with experience. Salaries vary quite a bit from around the U.S. and it depends a lot on the competition for the jobs available. Salaries can vary as much as from $30,000 to $45,000 depending on training, experience and how much experience one has in this field.

I see classified ads occasionally that are for medical billers but the ad does to always use this designation. It will say medical insurance specialist or billing assistant or something related so keep this in mind.

You can get training in medical billing or coding or both online or on your local college campus. Online training can be cheaper sometimes but you need to read any contracts carefully and check out the schools thoroughly.

Your local college reps can tell you whether they have a program in medical billing and/or medical coding. A number of subjects will need to be covered such as medical terminology. With some of the online schools you want to make sure that you actually need all the classes they recommend as it may cost more money. Federal financial aid is available for medical coding or billing online classes as well as for classes at your local schools, trade schools, colleges and universities and some of these institutions also have online classes you can combine with attending locally or taking the classes strictly online. Make sure to do your in initial research online for comparison's sake.

Getting Your Money's Worth Using The Medical Loss Ratio

The Affordable Care Act (ACA) contains a provision called the "medical loss ratio". This provision is to make the insurance marketplace more transparent and allow consumers the ability to purchase plans that make the best use of their premium dollars. Over 20 percent of consumers are now in plans that spend about 30 cents per dollar on administrative costs. Some insurance companies spend more than 50 percent of premium dollars on administrative costs. This new provision will eliminate the overspending on administrative costs and improve the value of the money spent by consumers on their health care premiums.

It is estimated that the new rule will protect about 74.8 million insured Americans in 2011. It is also estimated that almost 9 million people could receive rebates in 2012. The estimation of the amount of rebates is $1.4 billion. In the individual market the average rebate per person could be $164.

Insurance companies will be held accountable for their spending by the medical loss ratio. This will increase the value of consumers' premium dollars and will be accomplished in three ways beginning in 2011. First, insurance companies will be required to report publicly how the premium dollars they received were spent. This provides consumers an accounting of how far their money went to improving health care quality.

Second, insurance companies who provide individual and small group policies will be required to spend at least 80 percent of premium dollars on medical care and quality improvement. Insurance companies who provide large group policies will have to spend 85 percent on medical care and quality improvement.

The third way is to provide rebates to consumers when insurance companies don't comply with the medical loss ratio. The first rebates would occur in 2012 and would need to be paid by August 1 of each year. Consumers might receive a premium reduction, receive a rebate check, or have the amount returned to whatever account the premium was paid from. If the premium was paid by an employer then the employer would receive the rebate amount.

Health insurance companies will have to report certain information to every State where they do business. This information includes total premium amounts received, total reimbursement for clinical services, total spending on quality improvement and total spending on all other costs. These reports will then be publicly posted so every State resident will be able to see the value of health plans that are in their State.

The regulation specifies a set of comprehensive quality improving activities that an insurance company may implement and that can be counted toward the 80-85 percent spending standard. These activities must be evidence-based medical practices and the insurance company must be able to show measurable results. These activities must be based on the specific needs of patients and be designed to increase a desired health outcome. An example is having a case manager follow-up with diabetic patients to encourage them to follow their medical plan and decrease hospitalizations.

Health insurance companies are required to send their reports to the State by June 1 of each year. The first year it will be due is 2012 which will contain the 2011 data. Rebates will then be due by August 2012 based on the 2011 medical loss ratio.

The ACA has stipulations that are intended to prevent market destabilization and ensure continued access to health coverage. The reporting requirements and the way the medical loss ratio is calculated has been designed to take special circumstances into account.

The Secretary of the HHS can adjust the medical loss ratio standard for any State. If meeting the 80 percent standard will destabilize the individual health insurance market, the standard can be adjusted for that State for up to three years. The State must show that the 80 percent requirement will destabilize the market and that there will be fewer health plan choices for consumers.

The ACA gives the HHS Secretary direct enforcement authority over the medical loss ratio requirements. The States rights and capacity to assist in enforcement will still be recognized. Part of the enforcement includes requiring health insurance companies to retain documentation relating to the data they reported. They also have to allow access to their data and facilities for verification that they are complying with all of the regulations.

The overall intent of the medical loss ratio is to improve health care and lower health care costs. Allowing people to see where their dollars are spent will force health insurance companies to improve their spending and also to improve how they provide health care to their consumers.