As a Medical Biller and Coder, you will submit claims to third-party payers for reimbursement of services rendered. Try to set up your claim to be payer specific because you want the claim to be paid after the first submission. There are remittance advices sent to the Medical Biller and Coder from the third-party payer that help to inform you if the claim has been denied, paid, or pending. If your claim has been denied or pending than you can begin your investigation to figure out the reason(s) for the nonpayment of services rendered.
The most common reason for a denial of a claim is that the information given about the patient on the claim form is not correct (Fordney, 2010). The information may have been incorrectly typed for the following: date of birth, insurance group identification number, wrong sex of patient, or the insured’s address. These mistakes happen, but most of the time we can prevent them from happening. Being the Medical Coder and Biller, you must slow down and review all the information you have to help build the claim. The main document that would be helpful in resolving incorrect patient information is looking over the patient registration form. Check with the front desk reception, if you see it has not been updated in a while then inform them of this matter. Keeping the patient’s registration form up to date is crucial. By doing this, will ensure that you are charging the correct insurance company, and that you are customizing the claim to that third-party payers specifics. If you are still having trouble figuring out the problem with the claim, then contact the third-party payer. The majority of the time, they can be very helpful in directing you on how to correct the claim.
Another reason for denial of a c...
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... of the timely filing clauses in the third-party payer participation agreements. Remember, these third-party payer participation agreements can change every six months to a year. Memos are a fantastic way of keeping everyone informed about all the participating providers. When working in an office everyone is an indispensable employee, as such everyone needs to know what is happening with the participating providers. With these steps in place it will help ensure the office’s accounts receivable management ratio is high, which in turn will allow the office to keep running properly and depending on your employer a bonus.
References
Fernec, D. (2014). Understanding hospital billing and coding. (3rd ed.). Saint Louis, MO: Elsevier Saunders.
Fordney, M. (2010). Insurance handbook for the medical office. (11th ed.). Maryland Heights, MO: Saunders Elsevier.
“Hospitals today are growing into mighty edifices in brick, stone, glass and marble. Many of them maintain large staffs, they use the best equipment that science can devise, they utilize the most modern methods in devoting themselves to the noblest purpose of man, that of helping’s one’s stricken brother. But they do all this on a business basis, submitting invoices for services rendered.”
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
In addition to costly outliers, both the IPPS and HH PPS share other similar payment adjustments in order to ensure that all eligible beneficiaries have access to the appropriate services. They include adjusting the payment rate for partial episodes, and low-utilization of services. The outlier adjustment is made in order to pay for beneficiaries whose cost of care exceeds the threshold amount for their assigned group, just as for the IPPS 3. Under the HH PPS, the low-utilization adjustment can be made for beneficiaries whose episodes consist of four or fewer visits. When this is the case, workers will be paid based on the services they provide per visit multiplied by the number of visits provided during the episode 3, 4. One additional payment adjustment made under the HH PPS, the partial episode payment adjustment (PEP) can be made for patients who change HHAs or are discharged and readmitted within a 60-day episode. When this happens, a new episode will begin for that patient and they would now required a new plan of care and assessment. The adjustment to the original 60-day episode proportionately reflects the length of time the patient remained under the agency’s care
In recent times, healthcare organization across the nation are facing unprecedented challenges as they strive to improve the overall quality of care provided to their patient’s population, while improving their organization’s financial performance. Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations.
Medical billing transforms health care services into billing claims. The responsibility of the biller is to follow that claim to ensure the physicians, hospitals, third party billing companies, as well as federal and state governments receive reimbursement for the work that is provided. An experienced biller can boost revenue performance for the facility while keeping the business running smoothly.
Showalter, J. S. (2012). The Law of Healthcare Administration (6th ed.). Chicago, IL: Health Administration Press.
Since the quality of healthcare would not suffer, the only thing to lose through maximizing efficiency is a bunch of waste. Through its administrative simplification advocacy, the American Medical Association (AMA) claims that up to 14% of a physician’s revenue is taken up by administrative waste. The goal of the administrative simplification is to inspire physician practices to use computerized, instantaneous health plan transactions, minimize manual procedures through the claims revenue cycle, while increasing transparency and reducing vagueness with the payment process involving the insurance company. It is the AMA’s hope to push this movement into high gear, getting more practices on board and to eventually see a decline in wasteful and inefficient administrative
Ghosh, C. (2013). Affordable Care Act: Strategies to Tame the Future. Physician Executive, 39(6), 68-70.
Crowley, Ryan A., and William Golden. "Health Policy Basics: Medicaid Expansion." Annals Of Internal Medicine 160.6 (2014): 423-426. Academic Search Complete. Web. 18 Apr. 2014.
The Healthy Body Wellness Center 's (HBWC) Office of Grants Giveaway (OGG) provides medical grants to hospitals and facilities. The company 's mission is to promote improvements in the quality and usefulness of medical grants through federally supported research, evaluation, and sharing of information. As part of fulfilling the businesses objectives of the HBWC OGG has contracted with We Automate Anything (WAA) to design and implement the Small Hospital Tracking System (SHGTS). The SHGTS is vital in the current functioning of the OGG as part of the HBWCs mission statement, and allows for the monitoring and distribution of grant funds. The SHGTS also functions to coll...
We are here to listen and legally define your situation of concern, and advise you on your corresponding legal rights. If your case is valid for a clinical negligence claim, we will further assist you in every step of the way.
McDonough, John E., and Eli Y. Adashi. "Realizing the Promise of the Affordable Care Act--January 1, 2014." JAMA: The Journal Of The American Medical Association 311.6 (2014): 569-70. Print.
This system provides annual statics on Medicare payment amounts for institutional providers. A nurse leader can use HCRIS to find other similar institutions with whom to compare reimbursement rates and use this information to make necessary adjustments (“Healthcare Cost Report”, 2016). Lastly, nurse leaders can also use cost-to-charge ratios, volume-based measures, per diem rates, and balanced scorecards to gain better insight of unit reimbursement (Liberty University,
a. The adage of the adage of the adage of Why you need your own malpractice policy? RN. 48 (March 2009) (pg. 1). 59) Nursing and Allied Health Collection. 16 Mar. 2014
Although insurance has been around for centuries, Sidney R. Garfield, a young surgeon, took the initiative and laid the foundation...