Medical Billing Facts

Medical Billing Fact: Insurance carriers spend in excess of $19 billion annually processing paper claims. Fact: Healthcare providers spend more than $7 billion annually just submitting claims to carriers.Fact: According to the New England Journal of Medicine, the U.S. Healthcare System wastes up to 24 cents out of every dollar on administrative and billing costs, or in excess of $6 billion annually.Fact: 30 to 35% of all paper claims are rejected due to typo's, errors and omissions.Fact: Less than 1% of electronic claims are rejected.  Medical billing fact An electronic claim takes just seconds to prepare. Fact: Most electronic claims are processed for payment by carriers within 24 hours.Fact: Electronic claims cost healthcare providers between $1.50 and $3.00 depending on volume,...

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What is ClearingHouse ?

In Medical billing Clearinghouses are a major part of a billing service's ability to conduct business. Your professionalism and reputation depend on aligning yourself with a reputable clearinghouse.What exactly does a clearinghouse do? Well, for one thing, they check claims for accuracy. But, the biggest thing they do is re-format the data you send to them to a format that a given carrier can read.Clearinghouses charge fees in many ways. Some charge an initial start up fee to the billing service ranging from $125 to $300. Others are free to sign-up with initially. Some charge a provider enrollment fee for every healthcare provider you enroll, while others don't. Most of them charge a per claim fee of some sort, depending upon the carrier.In the last couple of years, clearinghouses have adjusted...

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Useful provider related links

Useful Websiteshttp://www.upinregistry.com/provider_form.aspProvider UPIN search Enginehttp://www.cms.hhs.gov/NationalProvIdentStand/01_overview.aspNPI Application onlinehttp://upin.ecare.com/UPIN numbers are required for insurance billing specifically for referral based practices.This UPIN Number corresponds with the referring provider.http://www.healthlink.com/tech_tip_taxonomy_code.aspNeed to know your Taxonomy code? Look it up here!http://www.upinregistry.com/provider_form.aspRegister your UPIN number and begin the search engine for other provider to access your UPIN number.http://www.insurance.wa.gov/Need to contact the Washington State Insurance Commissioner?http://www.appeallettersonline.com/Online resource to assist your office in overturning denials, motivating insurers to pay more...

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The Glossary of Insurance and Medical Billing Terms

ICD-9A 3 to 5-digit number code describing a diagnosis or medical procedure.Inpatient A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.In-Network ProviderPhysicians and other service providers who are contracted with a managed care plan.Out-of-Network ProviderPhysicians who are not contracted with a managed care plan.OutpatientA patient who receives health care services, but is not admitted to a hospital during a 24-hour period.Primary Care PhysicianA physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the...

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UNITED STATES AND ITS CODES

Alabama ALAlaska AKAmerican Samoa ASArizona AZArkansas ARCalifornia CAColorado COConnecticut CTDelaware DEDistrict of Columbia DCFederated States of Micronesia FMFlorida FLGeorgia GAGuam GUHawaii HIIdaho IDIllinois ILIndiana INIowa IAKansas KSKentucky KYLouisiana LAMaine MEMarshall Islands MHMaryland MDMassachusetts MAMichigan MIMinnesota MNMississippi MSMissouri MOMontana MTNebraska NENevada NVNew Hampshire NHNew Jersey NJNew Mexico NMNew York NYNorth Carolina NCNorth Dakota NDNorthern Mariana Islands MPOhio OHOklahoma OKOregon ORPalau PWPennsylvania PAPuerto Rico PRRhode Island RISouth Carolina SCSouth Dakota SDTennessee TNTexas TXUtah UTVermont VTVirgin Islands VIVirginia VAWashington WAWest Virginia WVWisconsin WIWyoming WYArmed Forces Africa AEArmed Forces Americas AAArmed Forces Canada...

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Glossary - Payments

In Medical billing payment related terms are very important for follow up with insurances.Payments• Deductible• Explanation of Benefits (EOB)• Bundled Payment• Transaction Control Number (TCN)• Rejection & Reviews• Out of Pocket ExpensesDeductible:The amount of expense an insured must first incur before insurance begins payment for covered services.Explanation of Benefits (EOB)After an insurance carrier processed a claim, and the claim is paid, a document known as an Explanation of Benefits is usually issued to the Provider who receives along with a payment check and to the Insured, if the benefits have been assigned. If the claim has not been assigned, payment goes to the patient and the physician may have a difficult time obtaining this paymentIn General EOB is also called asStatement...

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Medicare Plan or Part D

Its a program for Prescription drugs. Its not like Part A or Part B. Patient has to pay their own premum to buy this services. Its run by private companies.All plans will have different costs and benefits from year to year, thus it is advisable for all beneficiaries to consider their options and make the best choice they can.Coverage and DeductibleThe Medicare law establishes a standard Part D drug benefit. Plans must offer a benefit package that is at least as valuable as the standard benefit. The standard benefit is defined in terms of the benefit structure, not the particular drugs that must be covered. In 2009, this standard benefit includes an initial $295 deductible. After meeting thedeductible the beneficiaries pay 25% of the cost of covered Part D prescription drugs, up to an initial...

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Medicare

Know about Medicare• Medicare EOB• Payment Floor• Waiver of Liability• Crossover• Freelook (Medigap)• Development letterMedicare EOB:Medicare used to mail Remittance Advice (RA) to providers and the patient receives a Beneficiary RA. RA has been replaced by Medicare Remittance Advice also called the Medicare Summary Notice. Electronic Claim sending offices receive Electronic Remittance Advice (ERA), The ERA post payments automaticallyPayment Floor:The timeframe established for carrier payment Of Medicare Part B claims. As of October 1,1993, electronically submitted claims will be paid 14 days after the date of receipt, while paper claims will be paid 27 days after the date of receipt. All clean claims (claims which do not require additional development or other documentation for processing),...

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Glossary (A-C)

What is ABN(Advance Beneficiary Notice) (Waiver of Liability)A written notice given to the patient by the Provider in advance of any service or supply furnished for which payment may be denied or reduced by Medicare as not reasonable and medically necessary. This notification serves as protection for both the Provider and the patient. GA modifier is used to denote waiver of liability. It is also called as Advance Beneficiary NoticeAssignment of insurance benefitsAn authorization granted by the patient to allow the insurance company to pay claim benefits directly to the provider of care. It is to the provider's benefit to have the patient sign the "assignment of benefits" statement on each claim form. All benefits due to the provider will be mailed directly to the provider rather than to the...

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Glossary D-M

What is Durable Medical EquipmentEquipment that can withstand repeated use, is primarily and usually used to serve a medical purpose, is generally not useful to a person in the absence of illness or injury, and is appropriate for use in the home. To be covered, durable medical equipment must be medically necessary and prescribed by a contracting physician for use in the home. Examples are oxygen equipment, wheelchairs, hospital beds, and other items that the insurance company determines are medically necessary, in accordance with Medicare laws, regulations and guidelines.E Codes:E Codes are supplementary classification of coding in which you look for external causes of injury rather than disease. The use of an E code after the primary or secondary diagnosis tells the insurance carrier what...

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W9 Form Download

Hi Friends,Click the following link to download W9 form.http://rapidshare.com/files/93592292/fw9.pdf.h...

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Glossary N - P

What is Non-Participating.In this scenario then the AR needs to identify if out-of-network benefits would be given to a particular patient under this Insurance in some cases the Insurance does not pay for out of network benefits, whereas in other instances there is a penalty of low reimbursement rate, and a slower processing time. Therefore these considerations need to be looked at critically in order to effectively coordinate the collection level.What is NPI?The National Provider Identifier (NPI) is another key initiative, which will help in the prevention of fraud and abuse.NPI is an industry wide unique identifier for providers and suppliers created under the authority of the Health Insurance Portability and Accountability Act of 1996.CMS developed the NPI effective from 1st Jan 1997.The...

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NPI Application and Updation form

Hi you can download a NPI Application and updation formClick the following link to DOWNLOADhttp://rapidshare.com/files/95266645/NPI_Application_and_update_form.pdf.h...

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Medicare coverage - Physician Expense for Surgery, Childbirth, and Treatment for Infertility

Surgery and ChildbirthSkilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care. Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e., where the life of the mother would be endangered if the fetus were brought to term), the need for skilled medical management and/or medical services is equally important as in those cases carried to full term. After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mother’s eligibility.Most surgeons and obstetricians bill patients an all-inclusive package charge intended to cover all...

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Reasons for Claims Denial

In addition to pended claims, claims processing may also result in the denial or rejection of claims. These claims may very well have come in as clean claims; however, some reason has been determined for the nonpayment of the claim. On average, 14 percent of claims received were denied for payment. Almost half of all claim denials (48 percent) were due to the submission of a duplicate claim. Some plans indicated that though a claim may have been initially submitted electronically, there often is a paper claim received that unnecessarily follows up to confirm the submission. A claim for a noncovered benefit, or for an individual who is no longer covered or whose policy has lapsed, each represented about 20 percent of rejected claims.1. Non covered benefit2. Eligibility issues3. Coverage...

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Why clean claims are best ?

Proportion of “Clean” ClaimsThe vast majority of claims received, whether electronically or on paper, are “clean” and do not present problems with missing information or format errors. Claims received electronically have some advantage over paper claims across all provider categories surveyed. On average about 94 percent of claims received electronically are clean versus 86 percent of paper claims. Physiciansdo slightly better on their percentage of clean claims than do hospitals (97 percent versus 94 percent for electronic claims and 89 percent versus 87 percent for paper), and both do better than other health care providers.Automatic Adjudication of Claims Electronically submitted claims have a large advantage over paper in the automatic adjudication of claims (claims processed without...

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What Is an Appeal? and how to appeal the denial?

What Is an Appeal?An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan.You can appeal if Medicare or your plan denies one of the following:A request for a health care service, supply, or prescription thatYou think you should be able to getA request for payment for health care services or supplies or aPrescription drug you already got that was deniedA request to change the amount you must pay for a prescription  drugYou can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.If you decide to file an appeal, ask your doctor or other health care provider or supplier for any information that may help your case.How to File an AppealHow you file...

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Medicare Top ten Claim denials and how to resolve insurance denial?

Top 10 Claim DenialsWhat should you do when you get a denial?• Do you file a new claim?• Request an appeal?• Top denials will be discussed      o Denial codes and descriptions      o Reason denial occurred      o How to resolve and avoid future denials1. Denial Code CO - 4Denial Message• The procedure code is inconsistent with the modifier used, or a required modifier is missing (04) Reason for Denial• Claim was filed with a procedure code and modifier that did not correspond.How to resolve and avoid future denials • Verify that the procedure code and modifier descriptions correspond with each other• File claims with consistent procedure code and modifier descriptions• Access the Modifier Lookup tool on www.PalmettoGBA.com/bsc...

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Medicaid denial reason code list

Medicaid Claim Denial Codes1  Deductible Amount2  Coinsurance Amount3  Co-payment Amount4  The procedure code is inconsistent with the modifier used or a required modifier is missing.5  The procedure code/bill type is inconsistent with the place of service.6  The procedure/revenue code is inconsistent with the patient's age.7  The procedure/revenue code is inconsistent with the patient's gender.8  The procedure code is inconsistent with the provider type/specialty (taxonomy).9  The diagnosis is inconsistent with the patient's age.10  The diagnosis is inconsistent with the patient's gender.11 The diagnosis is inconsistent with the procedure.12 The diagnosis is inconsistent with the provider type.13 The date of death precedes the date of service.14...

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Medicaid Claim Denial Codes - List 2

Medicaid Claim Denial Codes129 Payment denied - Prior processing information appears incorrect.Note: Changed as of 2/01130 Claim submission fee.Note: Changed as of 6/01131 Claim specific negotiated discount.Note: New as of 2/97132 Prearranged demonstration project adjustment.Note: New as of 2/97133 The disposition of this claim/service is pending further review.Note: Changed as of 10/99134 Technical fees removed from charges.Note: New as of 10/98135 Claim denied. Interim bills cannot be processed.Note: New as of 10/98136 Claim Adjusted. Plan procedures of a prior payer were not followed.Note: Changed as of 6/00137 Payment/Reduction for Regulatory Surcharges, Assessments, Allowances or HealthRelated Taxes.Note: New as of 2/99138 Claim/service denied. Appeal procedures not followed or time limits...

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Medicaid rejection list - 3

Medicaid Claim Denial CodesA0 Patient refund amount.A1 Claim denied charges.A2 Contractual adjustment.Note: Inactive for version 004060. Use Code 45 with Group Code 'CO' or use anotherappropriate specific adjustment code.A3 Medicare Secondary Payer liability met.Note: Inactive for 004010, since 6/98.A4 Medicare Claim PPS Capital Day Outlier Amount.A5 Medicare Claim PPS Capital Cost Outlier Amount.A6 Prior hospitalization or 30 day transfer requirement not met.Note:A7 Presumptive Payment AdjustmentNote:A8 Claim denied; ungroupable DRGB1 Non-covered visits.Note:B2 Covered visits.Note: Inactive for 003040B3 Covered charges.Note: Inactive for 003040B4 Late filing penalty.B5 Payment adjusted because coverage/program guidelines were not met or wereexceeded.Note: Changed as of 2/01B6 This payment...

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INAPPROPRIATE MODIFIER USAGE denial AND UNPROCESSABLE CLAIMS

A modifier is a two-position alpha or numeric code that is added to the end of a Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) code to clarify the service(s) being billed. Modifiers provide a means by which a service is altered without changing the procedure code. They add more information, such as the anatomical site, to the code. The Multi-Carrier System (MCS), Medicare's claim processing system, denies claims as "unprocessable" for inappropriate modifier use. "Unprocessable" means the claim is missing certain information or the information present is incorrect. Unprocessable claim denials to not have appeal rights, you must correct the claim and resubmit it for a proper initial determination. Your Remittance Advice (RA) identifies unprocessable claims...

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Insurance denial - Some basic terms which we need to know

Reason Codes• Provide information about claim decisions• Tells why a claim was paid differently than it was billed• CO, PRRemark Codes• Numerical codes that further explain the denial• Indicate if/what appeal rights apply• B, M, MOA, and NCO: Contractual Obligation• Patient cannot be billed• Provider filing error• Provider must correct and file a new claimPR: Patient Responsibility• Patient can be billedWhat should you do when you get a denial?• Do you file a new claim?• Request an appeal?o How to resolve and avoid future deni...

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How to avoid insurance denial - Best six points to remember.

Insurance claim denials can be costly for any family medicine practice. Denials may lead to one of two different scenarios:A. If the denial is not applicable, your practice will experience a loss of income for a service already performed; or,B. You will incur increased expense in appealing the denial — a situation no practice wants to be faced with, particularly as reduced payment from many payers affects practice income.How to avoid insurance denial Here are the important points1. Verify Insurance Plan Coverage every time: While this may seem obvious, in fact the number of claims denied or returned because the wrong insurance carrier is billed is staggering. It is the number one reason claims are not paid upon first submission.2. Billing for services found to be “medically...

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