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Medical Billing

Medical Billing

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Published by sensiva884523
General concepts about medical billing
General concepts about medical billing

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Published by: sensiva884523 on Mar 11, 2010
Copyright:Attribution Non-commercial


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Health Care Entity :* Patient * Provider * PayerPatient - Who goes for treatment or general checkup.Provider - Any one who gives health care facilities. E.g. Doctors, Physicians etc.Skilled Nursing Facility : The Nurses, who is present in the place of Doctor, For E.g. Coma Patients, sitting the next to the patient all the time in the placeof doctors.Hospice : Terminally ill patient, the patient who is going to die within a shortspan of time, will be brought to the hospice place & treatment.Home Health Agency - Home Health Agencies will help those people who done have anyone at home for taking care.Payers - Any persons who pays on behalf of the patients in general, but most ofthe people in US is insured.Billing Office - The office which maintains the financial transactions of the provider.Patient - Front Office Executive - Registration form - Encounter - Transcription- Transcribed sheet - Coding.Registration Form:Patient Details or Personal Details* Name * Gender M/FThe Name written as Last name, First name and Middle Initial* Date of Birth (MM/DD/YY) * Age * Marital status (Married/ Unmarried/Other)* AddressZIP - Always five digits + add on codes (XXXXX-XXXX) (Zonal Improvement Plan)* Telephone - (XXX-XXX-XXXX) 1st three is Area code.* SSN (Social Security No) - Which is given by SSA -Social Security Administration. It's nine digits no. (XXX-XX-XXX)2. Employer's Details3. Guarantor's Details - Its must in case of Minors, and Optional for Adults (Promissory notes).4. Insurance Details ( Name, Policy Id, Plan, Effective & Termination Date, Insurance Company Address, Telephone no, Claims Mailing Address)Card Copy is must.5. Co- Ordination of Benefits (COB) (Primary, Secondary and priority wise)6. Assignment of Benefits (AOB) - By signing AOB, the patient states that the se
rvice is received from particular provider, so asking the insurance company to pay the money to the provider on behalf of the him, that is subscriber.7. Release of Information(ROI) - The Personnel and all other information regarding the patient can be released only after signing ROI.8. Medical Recording Index no (MRI)- It's maintained for 3 years in the sense after 3 years from the last visit to the doctor, then he is considered as New Patient. The others are called Established Patient. After this, A account no. is given each visit is given a New A/C no.Inpatient - Who stays for more than 24 hrs.Outpatient - Who stays for less than 24 hrs.Coding- A predefined set of codes which contain Alpha Numeric values organized for diagnosis & procedures done by the provider.The Sheet where the coding is written, is called Charge Sheet.E-Claims are go to clearing house and Paper claims are go to insurance.Functions of Clearing House:Preliminary Screening - The checking will send the error claims to the billing office, and those claims are called dropped claims.Conversion to Insurance Specific Format - (NSF - National Standard Format & ANSI- American National Standard Institute)DespatchScrubber Report - The Scrubber Report contains, No. of claims received from billing office, No. of claims dropped to billing office. No. of claims which one dispatched. This report is sent to the billing office periodically.HCFA (CMS1500) - It's a professional bills form. It contains 33 fields. Physicians fees, bills are sent through CMS1500.(HCFA - Health Care Financial Administration, CMS - Center for Medicare & Medicaid Services)CMS1450 (UB - Universal Billing) - It's used for hospital billing - technical components like wheelchairs, x-rays, oxygen. It has 81 fields.Functions of Insurance Company for E- Claims:Pre Edit / Audit: The Error claims are sent to billing office which are called unprocessed claims.Claim Adjudication: Take a decision whether to pay or not. Denied claim- not topayCommunication of Decision : Sent to the provider by EOB or Remittance Advice orPayment Voucher. If Payable, then EOB is attached with a payment details & Cheque. If denied, then EOB is attached with denying codes & denying reasons, then the EOB denying statement is sent back to the billing offices by scanning.In Billing office, people called as Payment Posters / Cash Posters.
Payment Detail from Insurance CompanyAny payment from the patients.Any Denying, then enter itFunctions of ARE ( Accounting Receivable Executives) :Pre Call AnalysisMake the CallDocumentationPost Call AnalysisFunctions of Billing Office :Demo EntryCharge EntryCash PostersARE.CODINGThe assigning of predefined numeric and alphanumeric to procedure and diagnosiscalled coding.Classification of Coding:* Diagnosis * Procedure Code * ModifierDIAGNOSISDiagnosis codes are codes which are attached a particular diagnosis or an ailment. These codes are formulated by WHO. They are called as ICD ( International Classification Diseases) codes. We are ICD9-CM (clinical modification).Format for Diagnosis : XXX.X or XXX.XXICD-9CM classifieds into three categories they are follows:* Volume one contains numeric format * Volume two contains alpha numeric format* Volume three is used for Hospital Billing.Volume two are classified into two categories they are follows :* E-Codes * V-CodesE-Codes* E-codes is used to both the even during which the injury took place and the individuals who were injured.* E-Codes are mandatory on the death records for all persons whose deaths are injured related.

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