Medical Billing and Collection Process

Updated: November 27, 2021

In the healthcare industry, the medical billing and collection process is being considered the most complex process as the whole business and profitability relies on it. A good medical billing services company has extensive knowledge of denial management in healthcare to succeed in the process and to get the physicians paid faster. That is the reason healthcare providers prefer Outsourced Medical Billing Companies to take over their medical billing and collection process so they could have more time to focus on patient care, healthcare research and adopt unique ways to improve patient care.

What is Billing and Collection Process?

The Medical Billing and Collection Process is to enter the patient demographic information and insurance information into the medical billing software, prepare healthcare claims from clinical documents, perform a pre-submission audit, submit the claims to insurance carriers, fix rejection and denials to get the claims paid to the provider office. Due to its complicated nature, most healthcare providers prefer outsourced medical billing companies to work on the medical billing side of their business.

 

Patient Demographics Entry after Registration

The process of Medical Billing starts from the patient registration. When a patient calls in and asks for an appointment, the front desk receptionist registers the patient’s appointment. If the patient is new, upon vising the provider’s office, all the demographic and insurance information is taken to enter in the Practice Management Software.

Patient Insurance Eligibility & Benefits Verification

When the patient information is entered in the Medical Billing Software, insurance eligibility is being checked to ensure the accuracy of not only the patient information such as Patient Name, Date of Birth, Address but also the insurance information such as Insurance Name, Insurance Member ID and Insurance Policy Group Number. In some cases like Home Health Billing Process, patient benefits are also being verified to ensure that when the claim will be submitted, it should be covered by the insurance company.

Patient Charting in the Electronic Health Record

When patients visit the clinical office in the example of face-to-face encounter or have a virtual appointment and are being treated by the physician’s office, then a patient chart is created in the EHR/EMR Software. There is a slight difference between EHR and EMR but we will go into the details in a separate article. Once the physician identifies the reason for illness and services provided, relevant services are being selected in the EHR Software and the claim is being coded.

Healthcare Claim Coding

In the healthcare industry medical billing and coding, services are correlated to each other. If practice is not using any EHR Software and their office workflow is manual, then they need the coder to decide about the diagnosis and procedure code and even in some cases, EHR users do need this service. In general, doctors know the diagnosis codes and procedure codes (ICD & CPT Codes) and they select to create an encounter or healthcare medical claim.

Healthcare Claim Entry in the Medical Billing Software

If the healthcare practice workflow is automated, then there is no need for manual entry but if that’s not the case, then the medical billing team has to enter the healthcare claim into the Practice Management Software to submit to the insurance company. Each CPT code has its own charge amount and all the fee schedules are being managed in good medical billing software. We will dive deeper some other day in another article about the Physicians Fee Schedule and how this can help to increase practice revenue.

Medical Claim Submission to Insurance

Medical Billing Companies’ expert team of billers is expert in doing the pre-submission claim audit to ensure accuracy. A good medical billing software does have the functionality to run the claim for all possible errors generally called “Claim Scrubbing Tool”. Once everything seems okay, the claim is filed with the insurance company.

Medical Bill Collections Process

Once the claim is submitted, medical directors or in some auto accident cases medical claim adjusters review the claim and make the decision for reimbursement. Once the claim is finalized to pay then insurance releases an ERA (Electronic Remittance Advice) or EOB (Explanation of Benefit). These payment notifications are for patients, providers, and for medical billing companies. This doesn’t happen the same way and sometimes the claim gets denied as well.

Negotiate Medical Bills in Collections

When the claim is denied, then medical billing company experts have to engage with the insurance company to check the denial type, insurance company rules, claims timely filing limit, services coverage based on the patient plan to get the claim paid. Denial Management in the healthcare industry always plays a vital role to succeed in getting paid the claims faster and collecting every dollar.

Medical Bill Payment Posting

Once the payment is issued by the insurance company, all payment details are being updated in the Practice Management Software. Payment posting helps to determine if there is any patient responsibility left by the insurance to bill the patient.

Healthcare Claims Patient Billing

If there is any patient responsibility left after the claim is processed, that will be sent to the patient unless the patient paid in advance at the time of visit. The most patient knows about their PCP Copay and Specialist Copay and their Co-Insurance and Deductible Amount. Once the patient receives the statement and makes a payment then it will be applied to the patient account in Medical Billing Software.

If you need help in learning how iCareBilling can help you to streamline your office workflow to get you paid faster and take care of all the Medical Billing and Collection Process, Contact Us today to schedule an appointment with a Medical Billing Expert. Our goal is to help the healthcare providers so they could be more efficient in their work and let the Medical Billing task to us so we could take care of it for you.

Outsourced Medical Billing Companies and Healthcare Practices

Healthcare providers generally prefer Outsourced Medical Billing Companies to take over their medical billing tasks so they could have more time to focus on patient care, and healthcare research and adopt unique ways to improve patient care.

When comparing the Outsourced Medical Billing Companies workflow with the In-House Medical Billing team, healthcare providers prefer the Outsourced Medical Billing Companies which has a proven track record of delivering quality Medical Billing Service. Healthcare providers need to see an immediate result in improvement in the quality of medical billing tasks, and a positive impact on practice cash flow and collections. Some practices might not find the same answer as sometimes it depends on individual practice workflow and other relevant factors and they think it’s a wiser decision to stay with an in-house billing system where they have more control over the department but again it depends on the Medical Billing Company you are choosing. If you are fortunate enough to find the Best and Top Rated Medical Billing Company, you don’t need to worry about any problems and can focus on patient care.

In-house Medical Billing Team Workflow

  • Cost of Employee Payroll: Generally an in-house medical billing staff member costs a healthcare provider around $16 to $ 22 an hour depending on the location and state in the United States because some states have higher minimum monthly wage than others and it also differs from the candidate’s level of medical billing expertise.
  • Dependency and Billing Process Halt Possibility: Many healthcare professionals did experience that their one or more staff members are out of the office due to any reason and the billing process has been stopped or slowed down. In such cases, healthcare provider always looks for an efficient medical billing team at Medical Billing Companies around their area.
  • Higher Overhead Costs: When it comes to the budgeting for healthcare practice, after the building rent, payroll becomes the second priority. In case of practice is getting an increased number of appointments, this would result in more claims filing and such workload would result in hiring more staff or having current staff work more hours. All this ultimately places liability and burden on the expenses sheet which sometimes doesn’t seem feasible. With Medical Billing Companies, you only pay for what you have collected which makes sense in such situations.
  • Increased Liability on Healthcare Practice: Other than payroll and extra hours, having an in-house medical billing team can increase liability in cases of having sick/medical leaves, medical insurance coverage, maternity and/or paternity leaves along with annual raise in salary. All such costs add up on the practice ledge in the expenses sheet and after a certain time, healthcare practices have to move on to hire the Best Medical Billing Company that could catch up with things quickly and yet offer a cost-effective solution.

Outsourced Medical Billing Companies Processes

  • Only Pay for What You have Collected: Medical Billing Companies that have flexible pricing structures, only offer their clients to pay when they get paid and do not charge based on hours. In such cases, the cost of having an expert medical billing team is very low and you don’t need to worry about hiring and managing staff.
  • Lack of Negotiation Skills with Insurance: Medical Billing Company staff is trained to handle the situation and know the basics, how to communicate, negotiate, schedule meetings with insurance companies’ claims department managers, and medical directors, and can have them send the claims back for reprocessing and in-house billing team would lack such ability.
  • Flexibility in Medical Billing Services: Medical Billing Companies have the resources to offer 24 hours a day and 7 hours a week. The healthcare billing companies do have more resources to handle bulk work and as an individual practice owner, you can’t take this advantage by having your in-house billing team provide the same flexibility you get from a Medical Billing Company.
  • Up to Date with Healthcare Regulations: Medical Billing Companies always update their internal processes and keep themselves up to date with changes in the healthcare industry, insurance companies, and other regulatory requirements.
  • Regular Follow-up on Aged/Unpaid Insurance Claims: Medical Billing Companies have the process in place to regularly follow up on medical claims sent to insurance and not paid. Having separate Account Receivable Departments and regular follow-up on pending/unpaid or denied claims improve practice overall collection and you can collect more. The in-house billing teams generally undertake other office tasks and they do not get much time to improve practice indicators. For more details on how “Denial Management in Healthcare” can help in your practice to improve the monthly collection, please check our Guide on Denial Management in Healthcare.
  • Regular Medical Billing & Follow-Up Process: As a healthcare professional, it’s not your job to keep checking the claims are completed, sent out to the insurance company, and if the claims couldn’t go through due to inaccuracies in patient demographics or claims. When a Medical Billing Company is working on your medical billing tasks, they take care of everything to give you more time to focus on business operations.
  • Better Healthcare Business Growth: By having an efficient and expert medical billing team working on your accounts, you get plenty of time to do research, analyze the practice performance and make decisions to have better business growth.

If you are considering how a Medical Billing Company can help you to improve your workflow and collections, please Contact Us today and talk to a Medical Billing Expert to have a free consultation.

Tips to Improve Healthcare Practices Workflow

In healthcare practices, the front desk is the first department that deals with incoming patient call to schedule appointments, checking on the accepted insurances, injuring about the services being provided at the healthcare facility, and other details. On the office administrative side, the starting point of the workflow is from appointment scheduling, then face-to-face encounters at the office or the patient’s home, (if you are a home health agency or home care agency) or admitting the patient in hospital if long-term care is needed. It really does not matter the size of your practice, front desk office plays a vital role at healthcare offices.

Using the right technology such as Patient Appointment Scheduling Software, recording the patient co-pays and other patient payments, answering questions about patient pending balances make a significant role in your practice and you must have Good Medical Billing Software to ensure the accuracy and effectiveness in your process.

Delivery of Information:

Providing information about the most common questions is one important task being handled by the front desk receptionist at healthcare practices. Mainly patient calls in to check if their insurance is accepted and if the provider is credentialed or contracted with their plan or not. To reduce the incoming calls to get the information, a website can help with frequently asked questions along with online business profiles with common questions and their answers listed on it. This would improve the information delivery and you will get fewer calls.

Appointment Scheduling:

Many healthcare practices are using the Best Medical Billing Software’s which automate the appointment scheduling system such as patient can visit the website and schedule the appointment from the calendar and that website has a synchronization in place with Medical Billing System to avoid any duplicate appointments. But generally, people prefer to call the office and check the available appointments. Practices need to focus on using good healthcare technology along with having trained staff to ensure good service for incoming patients.

Information Processing

When patients provide their demographics and insurance information at the healthcare office front desk, the efficient workflow always involves updating the information into the right Practice Management System so the information can be accessed when needed. Putting information aside and thinking to take care of it in the future would create a mess in the office and later information can’t be accessed when needed because it was not handled properly.

Patient Charting and Encounters

Most physicians prefer an EHR System (Electronic Health Record) that has fewer tabs and steps to complete the patient charting. An HER system that is built by considering the physician’s needs in mind can improve your clinical workflow and you can complete the charting process in less time. If you are setting up your Practice, always check your specialty-focused EHR System and have a Specialty Focused Medical Billing Company so you could improve efficiency at every step.
Insurance Information

Top Rated Medical Billing Companies generally offer EHR & Practice Management System with built-in functionality to check patient’s insurance information eligibility on the date of service so you can have the correct and valid insurance information to submit a clean claim.

Selection of Good Medical Billing Company

All of your clinical and non-clinical workflows will be failed if you don’t have an efficient medical billing team to work on your claims and get you paid faster. You need a Medical Billing Company that has extensive knowledge about Denial Management in the Healthcare industry and they can provide you with the right resources to help you get paid faster.

iCareBilling is helping many physicians like you and get them paid faster so the healthcare providers can focus on what they have been trained for which is “Patient Care”. If you need help in streamlining your office workflow, Contact Us today to talk to a Medical Billing Expert.

Medical Billing and Denial Management in Healthcare

Denial Management in Healthcare should be the top priority for individual healthcare providers, group healthcare practices, and even larger healthcare facilities like hospitals and healthcare groups to stay profitable and get paid for most of the services. Healthcare administrators must focus on Assuming you’re dealing with an expanded number of claim denials which is going on month to month basis, that’s the sign that you really need to dig deeper and to find out why it’s happening and what exactly needs to be done to fix in Medical Billing process of your Practice if you have in-house medical billing team. If you continue to do the same practice over and over, this would negatively impact your healthcare business which will ultimately affect patient’s quality of care if you can’t cope up with medical billing challenges to run a smooth healthcare practice.

You will always have the option to learn about medical billing techniques and denial management in healthcare and have your billing team achieve the level of an expert medical biller and fix the issues which are contributing to the claim denials and rejections.

You must rely on Medical Billing Software to run some reports and identify the rejected and denied claims so you can take appropriate action. Generally, healthcare professionals think both are the same, but they are different. As soon as you are able to identify them you would be in a better position to take action based on their failure reason to go through into the insurance system or to have them get paid.

Electronic claims are being sent through a clearinghouse and such EDI Vendors do have set rules for a claim to met and then they pass the claim to the insurance company. Such rules are based on Member Insurance and Claims Clinical Information to ensure accurate claim delivery to the insurance system. If a claim is rejected by Medical Billing Software internal audit check, generally called “Claim Scrubbing Tool”, that is called rejected claim in healthcare. A good medical billing practice always has the process to identify such claims and resubmit them to the insurance company to get them processed and be on file in the insurance system for possible reimbursement.

The denied claims are generally considered a hard denial from the insurance company but that is not the case all the time. Denial Management in Healthcare has a certain practice that can be used to achieve the optimum level of collections for healthcare practices. All insurance denied claims can be due to different reasons and many billing mistakes can play a role to increase such numbers. All such claims can be resubmitted, and we can file an appeal and request an insurance representative on call to send the claim back for re-processing to get them reprocessed for reimbursement of the services provided. To deliver the “Good Medical Billing Service” we have outlined few major reasons for claims not getting paid and they are constantly getting denied or getting rejected by the clearinghouse.

1. Wrong Information Entry in Patient Demo

Claims can’t be processed by the insurance company which has incorrect patient information which always goes on claims such as patient name, wrong combination of first and last name, missing middle initial, wrong date of birth, address and especially wrong zip code and most important insurance member ID or insurance policy ID. On top of that, if wrong insurance is selected, the whole claim will be routed to the wrong insurance.

2. Inaccurate Primary Insurance Payment

One of the secondary claim denials is that when the medical billing team enters the primary insurance information on the Medical Billing or Practice Management Software, there could be wrong payment, adjustment, or allowed amount entered due to some technical error or human mistake. That will cause sending the wrong primary insurance info to the secondary insurance and claim will be processed incorrectly or will be denied completely if the combination of claim charge amount, claim allowed amount, claim paid amount, claim patient responsibility or and claim contractual adjustment doesn’t match with each other.

3. Service Not Authorized

Some insurances and some services do require prior authorization before performing the services and in such cases, you must bill only the authorized services. If the services provided to a patient are not included in the authorization form or authorization was not taken in the first place, there are higher chances of claims getting rejected by the insurance companies.

4. Invalid/Missing Diagnosis or Procedure Codes (ICD/CPT)

Entering the incorrect or expired diagnosis code (ICD Code) or not setting the appropriate diagnosis pointer to pinpoint the relevancy of diagnosis with CPT Code (Current Procedural Terminology)can cause the denial from the insurance company or rejection from the Medical Billing Software/EDI Vendor Claim Scrubbing Tool. When using the right modifier, it’s important to consider the patient’s charts and history to ensure accuracy.

5. Administrative Delay in Filing the Claim

There are few insurances that have very limited claim filing time. For example, some plans of United Healthcare only allow 90-120 days of timely filing limit. The most important thing which most physicians have to consider that claim filing starts from the DOS and it does count the holidays, just to make it clear it’s not business days it’s overall days. If there is an administrative delay in collecting the patient information, requesting patient the insurance information, or delay in processing the patient’s charts into the Electronic Health Record (EHR), then claims submission is delayed. If a claim is submitted after the claim filing limit, insurance denies such claims as “Timely filing limit expired”. If that happens, there are ways to get the claim processed by filing an appeal, but it depends on the scenario as you can’t take one corrective action on all types of denials.

6. Submission of Duplicate Claims

Sometimes claims are being created duplicates during the charting process in EHR (Electronic Health Record) or during the processing encounter creation in the draft section and encounter approval process. Most of the Medical Billing Software lack the ability to identify the duplicate claim to avoid submission and the Medical Billing team has to look at each claim manually to ensure that they are not submitting duplicate claims to the insurance. If a duplicate claim submitted to the insurance company, they have already received one, they will deny the recent claim as duplicate and you must wait for the original claim to be processed.

7. Physicians Not Contracted with Insurance

Some insurance companies like BCBS (Blue Cross & Blue Shield) require provider enrollment before submission of any claim. If the billing team is submitting the claims to insurance that require enrollment and the provider is not enrolled or credentialed, the claim will be denied. An Expert Medical Billing Team does have knowledge about the payer type, and its requirements so the claim submitted the first time could get on file and could be processed.

iCareBilling can Help to Fix Your Medical Billing Issues:

A Good Medical Billing Company has a follow-up process in place to regularly check the claims which are sent to the insurance companies and not paid. iCareBilling has a proven track record to deliver the best Denial Management in Healthcare and our specialized billing team constantly follow-up on each claim submitted to get you paid faster without facing challenges in medical billing. Contact Us today to schedule a consultation call with a Medical Billing Expert and discuss how we can help you to improve your collections and workflow to achieve maximum collection potential in your practice.

Merit Based Incentive Payment System MIPS

MIPS Healthcare Definition

The MIPS Healthcare is also known as Merit-Based Incentive Payment System (MIPS) is the program that will determine Medicare payment, adjustments, and/or penalties. The MIPS Healthcare system analyzes the performance score of eligible clinicians and they may receive a bonus payment, penalty, or no payment adjustment. The Merit-based Incentive Payment System (MIPS) is one among two tracks under the standard Payment Program.

What is a MIPS Healthcare or Merit-Based Incentive Payment System (MIPS)

MIPS Healthcare has 3 programs with unique conditions attached to them. One is Physician Quality Reporting System PQRS. The second one is the Value-Based Payment Modifier (VM) Program. The third one is Medicare Electronic Health Record (EHR) Incentive Scheme.

 

All Medicare Part B healthcare providers who meet the definition of MIPS eligible clinicians should participate in MIPS. In the past, if any eligible clinician didn’t participate in the MIPS program, they were subject to a 4% negative payment adjustment on Medicare Part B reimbursements. For more details, get in touch with your Medical Billing Company, and/or EHR Software Vendor.

MIPS Healthcare and Participation as Individual vs. Group Reporting

One unique aspect of MIPS Healthcare is that eligible clinicians have the option to participate as either a private or as a part of a group provider. A privately eligible clinician is supposed to report MIPS data to CMS under an NPI number that’s tied to their TIN. Two or more eligible clinicians (with unique NPIs) who have reassigned their billing rights to a single TIN have the choice to participate in MIPS as a group. If they are eligible clinicians prefer to participate in MIPS as a group, they’re going to be assessed as a group across all four MIPS performance categories.

MIPS Healthcare Definition, What is MIPS, Merit Based Incentive Payment System

MIPS Eligible Clinician types:

Physicians (includes doctors of medicine, osteopathy, dental surgery, dental medicine, podiatric medicine, and optometry; osteopathic practitioners; and chiropractors (with respect to certain specified treatment, a Doctor of Chiropractic legally authorized to practice by a State in which he/she performs this function)), Physician Assistants, Nurse Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Clinical Psychologists, Physical Therapists, Occupational Therapists, Qualified Speech-Language Pathologists, Qualified Audiologists, Registered Dietitians or Nutrition Professionals, groups or virtual groups that include one or more of these MIPS eligible clinician types.

Low-Volume Threshold Criteria for 2021:

Bill more than $90,000 for Part B covered professional services under the Physician Fee Schedule; AND
See more than 200 Part B patients; AND
Provide more than 200 covered professional services to Part B patients

To achieve QP status in 2021, you must:

Receive at least 50% of Medicare Part B payments; OR
See at least 35% of Medicare patients through an Advanced APM Entity.
Additionally, 75% of practices need to be using CEHRT within the Advanced APM Entity.

To achieve partial QP status in 2021, you must:

Receive at least 40% of Medicare Part B payments; OR
See at least 25% of Medicare patients through an Advanced APM Entity.

Important Notice and Change in Law:

The Consolidated Appropriations Act, 2021 was signed on December 27, 2020. Under this law, the Qualifying Participant thresholds for the payment for years 2023 and 2024 will be frozen at 50% for the payment amount threshold and 35% for the patient count threshold (Need to consider that the applicable performance years will be 2021 and 2022). The partial Qualifying participant thresholds have also been frozen at the same levels used for the 2022 payment year and 2020 performance year.

Reference:

2021 MIPS Overview, Eligibility Requirements & Reporting Measures