Here are some payer updates that will stand your medical coding & billing in good stead.
The findings of the American Medical Association’s (AMA) fourth annual National Health Insurer Report Card (NHIRC) do not paint a rosy picture. As per the association, commercial payers show an average claims processing error rate of 19.3 percent, notes an AMA press release. This is a two percent increase over last year.
Errors galore
According to the release, 20 percent error rate among health insurers talks of a great deal of incompetence that leads to a wastage of $17 billion annually.
Need of the hour
Keeping this huge inefficiency in mind, health insurers must put in more effort into paying claims correctly the first time to save money and bring down needless administrative tasks that take time and resources away from the patient, the release cites.
Payer rankings
As far as claims-processing accuracy is concerned, UnitedHealthcare was the only payer that showed a boost. The firm was ranked first in the list of seven leading commercial payers with an accuracy rate of 90.23 percent while Anthem Blue Cross Blue Shield figured in the bottom with an accuracy rate of 61.05 percent.
Legitimate pay may go unpaid by an insurer
What’s more, the report card also showed that you got no payment at all on around 23 percent of claims you submitted to commercial payers.
There are many reasons a rightful claim may go unpaid by an insurer, the release indicates. It may be denied, edited or deferred to patients. During February and March of this year, the most common reason insurers did not issue a payment was owing to deductible requirements that shift payment responsibility to patients until a dollar limit is surpassed.
Healthcare billing news: For many of the payers included in the report - Aetna, Anthem Blue Cross Blue Shield, Health Care Service Corporation and UnitedHealthcare - there were lower denial rates.
In addition, the report card indicates that Cigna and Humana cut their medical claims response time in half during the last four years.
Resource: More information is available at http://www.ama-assn.org/ama/pub/advocacy/topics/administrative-simplification-initiatives/national-health-insurer-report-card.page.
Showing posts with label healthcare billing. Show all posts
Showing posts with label healthcare billing. Show all posts
Thursday, September 8, 2011
Wednesday, August 31, 2011
Medical Billing & Coding: Don't Let Your Compassion Wreck Havoc on Your Payments
If your compassion's letting patients off the payment hook, it's time you took some action. Here's a medical billing and coding case study to help your understanding.
In a particular scenario, a physician tends to quite a few patients who were released because a local company shut shop. However, the physician wants to see those patients and also wants to ignore their copayments and deductibles.
Healthcare billing predicament: The physician wants to send the patient two bills, however he also wants them to ignore them. He wants the biller to write off the 'bad debt' after the second bill's sent out.
Here are three tips to ensure you are not setting yourself up for major troubles:
Stay away from potentially fraudulent exceptions
You should never tell patients to ignore the bills you send because you will write off the charges sooner or later. Although waiving of a fee for a professional courtesy or financial hardship may be nice, you may land yourself in a soup.
Reason: You must make a good faith effort in order to collect from your patients. Most practices send at least three statements to a patient to try to collect on an outstanding bill. It depends on your practice of how you make the good faith attempt.
What you need to do: Document your efforts – that's what you need to do.
Not only do you run the risk of hurting other patients who could not find out about the unfair policy, you could also be violating your payer contracts or even anti-kickback laws. You need to check your contracts with the insurers. Find out whether it's a violation to let go of these fees. You should not try this with federal programs. You may end up paying a heavy amount as the anti-kickback statute carries stiff fines.
In case you do waive payments, keep proof of financial hardship
You shouldn't think that you can write off a patient balance. If you have patients who cannot pay their balances owing to financial hardship, then you might want to consider writing off the balance after you've made an attempt to try to collect and you have got proof of financial hardship.
If your practice wants to write off a patient's bill owing to financial hardship, the patient needs to be able to prove he's unable to pay. For this, you should ask the patient to provide you with information like gross monthly income, assets, monthly household expenditures and number of dependants.
Your collection processes should be consistent
You also need to apply a consistent collections policy to all of your patients. If your normal process is to send a patient to collections if they do not shell out money, you have to follow the same medical coding guidelines( source "http://www.supercoder.com") with this patient.
In a particular scenario, a physician tends to quite a few patients who were released because a local company shut shop. However, the physician wants to see those patients and also wants to ignore their copayments and deductibles.
Healthcare billing predicament: The physician wants to send the patient two bills, however he also wants them to ignore them. He wants the biller to write off the 'bad debt' after the second bill's sent out.
Here are three tips to ensure you are not setting yourself up for major troubles:
Stay away from potentially fraudulent exceptions
You should never tell patients to ignore the bills you send because you will write off the charges sooner or later. Although waiving of a fee for a professional courtesy or financial hardship may be nice, you may land yourself in a soup.
Reason: You must make a good faith effort in order to collect from your patients. Most practices send at least three statements to a patient to try to collect on an outstanding bill. It depends on your practice of how you make the good faith attempt.
What you need to do: Document your efforts – that's what you need to do.
Not only do you run the risk of hurting other patients who could not find out about the unfair policy, you could also be violating your payer contracts or even anti-kickback laws. You need to check your contracts with the insurers. Find out whether it's a violation to let go of these fees. You should not try this with federal programs. You may end up paying a heavy amount as the anti-kickback statute carries stiff fines.
In case you do waive payments, keep proof of financial hardship
You shouldn't think that you can write off a patient balance. If you have patients who cannot pay their balances owing to financial hardship, then you might want to consider writing off the balance after you've made an attempt to try to collect and you have got proof of financial hardship.
If your practice wants to write off a patient's bill owing to financial hardship, the patient needs to be able to prove he's unable to pay. For this, you should ask the patient to provide you with information like gross monthly income, assets, monthly household expenditures and number of dependants.
Your collection processes should be consistent
You also need to apply a consistent collections policy to all of your patients. If your normal process is to send a patient to collections if they do not shell out money, you have to follow the same medical coding guidelines( source "http://www.supercoder.com") with this patient.
Thursday, August 25, 2011
Medical Billing & Coding: Hardware is a Vital Cog in 5010 & ICD-10 Implementations
From January 1 next year, your practice will have to make the required changes or enhancements to your practice management system, EMR system and/or medical billing and coding. Keeping this in mind, you need to work with your vendors to ensure your healthcare billing and practice management systems are up and running for the conversions to 5010 and ICD-10.
Communication with vendors a vital cog
It's very important that you get in touch with outside vendors to ensure the success of your practice's transition to version 5010 and ICD-10.
One more key to success is to test early and that too often
You should make it a point to test transactions and claim submissions with your vendor, clearing house and payer prior to the 5010 version deadline next year and the ICD-10 deadline in 2013. This step is very important for you to make a smooth transition.
Don't wait too late to test as your task will be tougher if you detect a flaw in your system in the last minute.
How to go about it: Get in touch with your software vendors well ahead of time to ensure that no issues will be there as far as claims submissions using ICD-10 are concerned. First you need to find out whether your vendors are all geared up for the transition to the just-in 5010 format.
Hardware requirements for your practice
Hardware is a vital peg for the 5010 and ICD-10 implementations. As such you need to assess the hardware your practice or vendor use. Find out the present age of your practice's hardware, the dual-processing capability for the two code sets (ICD-9 and ICD-10), storage capacity, processing power, and the like.
Also, you will need to see to it that your system is able to handle alphanumeric codes, seven characters, code descriptions which are long, just-in edits based on age, sex, and more, separate data entry programs for dual processing.
Your system is very important to be able to process both the soon-to-go ICD-9 code set and the soon-to-come ICD-10 code set concurrently to allow for claims processing, reporting and analysis.
The time required for maintaining both ICD-9 and ICD-10 will depend on your individual practice's requirement.
Source URL :- http://www.supercoder.com/icd-10/icd-10-bridge
You also need to see that your practice or vendor has a hardware that can handle the increased file and database storage you will need when the new code system goes into effect.
Communication with vendors a vital cog
It's very important that you get in touch with outside vendors to ensure the success of your practice's transition to version 5010 and ICD-10.
One more key to success is to test early and that too often
You should make it a point to test transactions and claim submissions with your vendor, clearing house and payer prior to the 5010 version deadline next year and the ICD-10 deadline in 2013. This step is very important for you to make a smooth transition.
Don't wait too late to test as your task will be tougher if you detect a flaw in your system in the last minute.
How to go about it: Get in touch with your software vendors well ahead of time to ensure that no issues will be there as far as claims submissions using ICD-10 are concerned. First you need to find out whether your vendors are all geared up for the transition to the just-in 5010 format.
Hardware requirements for your practice
Hardware is a vital peg for the 5010 and ICD-10 implementations. As such you need to assess the hardware your practice or vendor use. Find out the present age of your practice's hardware, the dual-processing capability for the two code sets (ICD-9 and ICD-10), storage capacity, processing power, and the like.
Also, you will need to see to it that your system is able to handle alphanumeric codes, seven characters, code descriptions which are long, just-in edits based on age, sex, and more, separate data entry programs for dual processing.
Your system is very important to be able to process both the soon-to-go ICD-9 code set and the soon-to-come ICD-10 code set concurrently to allow for claims processing, reporting and analysis.
The time required for maintaining both ICD-9 and ICD-10 will depend on your individual practice's requirement.
Source URL :- http://www.supercoder.com/icd-10/icd-10-bridge
You also need to see that your practice or vendor has a hardware that can handle the increased file and database storage you will need when the new code system goes into effect.
Wednesday, August 17, 2011
Medical Billing & Coding: Know How ERISA & PPACA Impact Your Practice
The Federal claims appeals regulations went into implementation on July 1. Here's an update on this and other medical billing and coding information relating to this change.
If you're not up to speed on the new law and honed your Employee Retirement Income Security Act (ERISA) know how, you could be taking your practice to a 'denial zone'. For the initiated, the Patient Protection and Affordable Care Act (PPACA) adopts existing ERISA claim regulation in total and adds on six to seven new standard requirements too.
The new appeals regs:
The just-in appeals regs will impact all your healthcare billing denials and appeals outside of Medicare and Medicaid; as such your billing department will need to be well-versed with them to get back their deserved payments.
The provider side of the healthcare industry does not focus enough on the new appeals regulation while the payer side of the industry talks about it all the time to ensure you don't get the payments.
Also bear in mind that PPACA is a Federal mandate and as such it's not optional.
Appeals options: Under PPACA, now there are both internal and external appeals options.
The good news is that for the internal appeals process, PPACA adopted ERISA claims regulations in their entirety and added six to seven new requirements as well. The law provides the just-in external appeals option by adoption the National Association of Insurance Commissioners (NAIC) external appeal model.
Note: As the practice or provider, you have no claim with the insurance company.
The appeal rights belong to the patient and not your practice; as such you need to get the patient's written permission to appeal a claim under ERISA. Under Federal Law, a provider or the representative of the provider can appeal an adverse benefit determination minus the written authorization by the member.
Under PPACA, if you have 'good assignment' from the patient, the healthcare provider will become a claimant during the appeals process.
PPACA requires one EOB format for the entire industry
A notable change is that PPACA requires explanation of benefits (EOBs) format for the entire industry. EOBs will be for initial denials called the adverse benefit determination, internal appeals denials (the final internal adverse benefit determination), and for external appeals denials (the final external adverse benefit determination).
Resource: For more information on the Federal claims appeals regulations, you can visit the labor department Website at http://www.dol.gov/ebsa/healthreform/.
If you're not up to speed on the new law and honed your Employee Retirement Income Security Act (ERISA) know how, you could be taking your practice to a 'denial zone'. For the initiated, the Patient Protection and Affordable Care Act (PPACA) adopts existing ERISA claim regulation in total and adds on six to seven new standard requirements too.
The new appeals regs:
The just-in appeals regs will impact all your healthcare billing denials and appeals outside of Medicare and Medicaid; as such your billing department will need to be well-versed with them to get back their deserved payments.
The provider side of the healthcare industry does not focus enough on the new appeals regulation while the payer side of the industry talks about it all the time to ensure you don't get the payments.
Also bear in mind that PPACA is a Federal mandate and as such it's not optional.
Appeals options: Under PPACA, now there are both internal and external appeals options.
The good news is that for the internal appeals process, PPACA adopted ERISA claims regulations in their entirety and added six to seven new requirements as well. The law provides the just-in external appeals option by adoption the National Association of Insurance Commissioners (NAIC) external appeal model.
Note: As the practice or provider, you have no claim with the insurance company.
The appeal rights belong to the patient and not your practice; as such you need to get the patient's written permission to appeal a claim under ERISA. Under Federal Law, a provider or the representative of the provider can appeal an adverse benefit determination minus the written authorization by the member.
Under PPACA, if you have 'good assignment' from the patient, the healthcare provider will become a claimant during the appeals process.
PPACA requires one EOB format for the entire industry
A notable change is that PPACA requires explanation of benefits (EOBs) format for the entire industry. EOBs will be for initial denials called the adverse benefit determination, internal appeals denials (the final internal adverse benefit determination), and for external appeals denials (the final external adverse benefit determination).
Resource: For more information on the Federal claims appeals regulations, you can visit the labor department Website at http://www.dol.gov/ebsa/healthreform/.
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