What You Need to Know About Medical Billing

You may think that hiring the services of a medical billing specialist will be like adding extra costs to your practice. But actually, hiring the services of a medical billing specialist can be considered as one of the smartest moves on your part in terms expanding your business.

Think about the ways you can be benefitted by them. Your already overworked staff won’t have to spend a large amount of their time at the copy machine because a majority of the records can be handled online, with the use of secure and encrypted technology. Medical billing specialists will ensure that the claims are properly coded and submitted in time. Your staff doesn’t have to face any interruptions with patients queries as those will be handled by these specialists. More over their style of developing Patient Statement barely leaves scope for queries.

But one can refer to a few things before hiring medical billing specialists. The top most questions to ask before hiring a medical billing specialist may include:

1. Qualifications and Certifications:

The most important requirement in terms of hiring is perhaps his/her qualification. Medical billing certifications are a necessary yardstick to determine whether a medical biller is qualified to take up the job. CPC, CPC-H, CCS-P, CCS, RCC, and OTR are some of the exams which can get a biller approved for Medical billing processes.

2. Experience:

Medical billers nowadays possess experience in a number of specialties. Before hiring a particular biller, ask if he/she has experience in your particular specialty, has understanding of applicable coding subtleties and questioning them about their style of payer follow up can be a good idea, most payers these days are keen on IVR communication, with which Billers must be familiar. Besides, they should also be able to come up with resolutions in case of claim rejection.

3. Location:

Medical billers and coders can be contacted from far and wide, in this day and age of electronic claim submission, physician offices also prefer home-based professionals. But some practices prefer local billers as they believe that local billers are more aware of the billing regulations of the state. But wherever they are located make sure that you don’t have to compromise on quality.

4. HIPAA Compliance:

Compliance to HIPAA regulations should be of top priority in order to ensure safety of PHI (Patient Health Information). Most medical billers claim to have adequate knowledge without really knowing the consequence of violation of HIPAA. So before hiring a medical biller , a clinic must verify the seriousness of the candidate towards information handling and avoid any leakage of crucial information.
 

5. Willing to learn your process:

Your medical billing specialist should be open to learn your style of operations. A medical billing specialist should be able to explain the various steps involved in medical billing as well as explain what steps they can take to meet your specific requirements. Hesitant Billers who avoid making concrete promises may create trouble for you in the long run, it is best to avoid them.

6. Payer exposure:

Denial rates and reasons vary amongst different payers. Careful scrutiny of the contract is necessary to understand the implications of various terms, rates as well as conditions given in the agreement thus saving you from some untoward surprises which you may have to face later on. Your Biller must be aware of the fee schedules and payer contracts for your specific specialty, they could help you improve your collections tremendously.

7. Nature of Reporting:

Being aware of the reporting pattern of your biller, may be a good idea. In general, reports are usually generated on a monthly basis but you can request them to develop special reports for your special needs. Financial Reports are the main tool to judge a billers performance, these reports can help you to enhance your productivity as well as fix problems.

 
Finally, you the provider have to fully understand ALL of the requirements of Medical Billing.
Medical Billing will include but NOT limited to :

HEDIS
Meaningful Use (MU)
PQRS (P4P) - Pay For Performance
ICD-10
Quality Measures
HIPAA
CCI  / LCD / NMP

 

Paul G. Silverio-Benet

www.accuchecker.com

 

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HIPAA Update

§ 164.306 Security standards: General rules.
       

(a) General requirements. Covered entities must do the following:

(1) Ensure the confidentiality, integrity, and availability of all electronic protected health information the covered entity creates, receives, maintains, or transmits.

(2) Protect against any reasonably anticipated threats or hazards to the security or integrity of such information.

(3) Protect against any reasonably anticipated uses or disclosures of such information that are not permitted or required under subpart E of this part.

(4) Ensure compliance with this subpart by its workforce.

(b) Flexibility of approach.

(1) Covered entities may use any security measures that allow the covered entity to reasonably and appropriately implement the standards and implementation specifications as specified in this subpart.

(2) In deciding which security measures to use, a covered entity must take into account the following factors:

(i) The size, complexity, and capabilities of the covered entity.

(ii) The covered entity's technical infrastructure, hardware, and software security capabilities.

(iii) The costs of security measures.

(iv) The probability and criticality of potential risks to electronic protected health information.

(c) Standards. A covered entity must comply with the standards as provided in this section and in § 164.308, § 164.310, § 164.312, § 164.314, and § 164.316 with respect to all electronic protected health information.

(d) Implementation specifications. In this subpart:

(1) Implementation specifications are required or addressable. If an implementation specification is required, the word “Required” appears in parentheses after the title of the implementation specification. If an implementation specification is addressable, the word “Addressable” appears in parentheses after the title of the implementation specification.

(2) When a standard adopted in § 164.308, § 164.310, § 164.312, § 164.314, or § 164.316 includes required implementation specifications, a covered entity must implement the implementation specifications.

(3) When a standard adopted in § 164.308, § 164.310, § 164.312, § 164.314, or § 164.316 includes addressable implementation specifications, a covered entity must—

(i) Assess whether each implementation specification is a reasonable and appropriate safeguard in its environment, when analyzed with reference to the likely contribution to protecting the entity's electronic protected health information; and

(ii) As applicable to the entity—

(A) Implement the implementation specification if reasonable and appropriate; or

(B) If implementing the implementation specification is not reasonable and appropriate—

$(1) Document why it would not be reasonable and appropriate to implement the implementation specification; and

$(2) Implement an equivalent alternative measure if reasonable and appropriate.

(e) Maintenance. Security measures implemented to comply with standards and implementation specifications adopted under § 164.105 and this subpart must be reviewed and modified as needed to continue provision of reasonable and appropriate protection of electronic protected health information as described at § 164.316.

[68 FR 8376, Feb. 20, 2003; 68 FR 17153, Apr. 8, 2003]

SBIRT

　

Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an evidence-based practice designed to identify, reduce, and prevent problematic use, abuse, and dependence on alcohol and illicit drugs. The SBIRT model calls for community-based screening for health risk behaviors. SBIRT offers an opportunity to identify problem drinking and substance abuse, and trigger intervention.

This fact sheet provides health care professionals with an overview of Medicare and Medicaid coverage of SBIRT services, including who may perform the services, documentation requirements, billing and coding guidance, payment information, and resources for additional information.

SBIRT consists of three major components:  

1. Structured Assessment (Medicare) or Screening (Medicaid): Assessing or screening a patient for risky substance use behaviors using standardized assessment or screening tools;
2. Brief Intervention: Engaging a patient showing risky substance use behaviors in a short conversation, providing feedback and advice; and
3. Referral to Treatment: Providing a referral to brief therapy or additional treatment to patients whose assessment or screening shows a need for additional services.

SBIRT Under Medicare Who May Provide SBIRT Services?
 Medicare pays for medically reasonable and necessary SBIRT services when you furnish them in physicians’ offices and outpatient hospitals. In these settings, you assess for and identify individuals with, or at-risk for, substance use-related problems and furnish limited interventions/treatment.

To bill Medicare overall, suppliers of SBIRT services must be:

 Licensed or certified to perform mental health services by the State in which they perform the services;


Qualified to perform the specific mental health services rendered; and  Working within their State Scope of Practice Act.  In addition to the three requirements listed above, Table 1 provides more information on the specific qualifications for suppliers authorized under Medicare to furnish SBIRT services.

SBIRT Assessment and Screening Tools

 The first component to the SBIRT process is screening. Screening tools include the World Health Organization’s Alcohol Use Disorders Identification Test (AUDIT) Manual and the Drug Abuse Screening Test (DAST).


Health Care Suppliers Eligible to Provide SBIRT Services

Physician
Physician Assistant : PA-C
Nurse Practitioner - NP
Clinical Psychologist - CP
Clinical Nurse Specialist - CNS
Certified Nurse Midwife - CNM


How Must I Document SBIRT Services?
 

Information in the patient’s medical record must support all claims for Medicare services. The medical record for covered SBIRT services must:

Create complete, legible medical records;

Denote start/stop time or total face-to-face time with the patient (because some SBIRT Healthcare Common Procedure Coding System [HCPCS] codes are time-based codes);

Document the patient’s progress, response to changes in treatment, and revision of diagnosis;

Document the rationale for ordering diagnostic and other ancillary services, or ensure that it can be easily inferred;

For each patient encounter, document: Assessment, clinical impression, and diagnosis;

Date and legible identity of observer/provider;
 Physical examination findings and prior diagnostic test results;
 Plan of care; and

Reason for encounter and relevant history;

Identify appropriate health risk factors;
 Include documentation to support all Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) codes reported on the health insurance claim; ( PENDING ICD-10 )


How Must I Bill and Code SBIRT Services?
Medicare
 


HCPCS Code G0396  




Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST), and brief intervention 15 to 30 minutes
 HCPCS Code G0397
 Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST), and intervention, greater than 30 minutes

Changes 2014-15

Changes implemented by Medicare in 2014 and the how to ensure that these challenges are met for the rest of 2014-2015:

 

We are into the second half of 2014 and it's time to identify and correct your compliance and regulatory areas of concern for the remainder of the year and 2015. Medicare compliance has become even more challenging with a number of regulatory and federal changes implemented in 2014 and what's about to come for 2015. Heightened federal scrutiny and penalty enforcement have physician practices/hospitals across the healthcare spectrum concerned that even a genuine error might result your practice to come under some serious scrutiny and unpleasant payback requests. You need to stay abreast with some of the latest updates implemented by Medicare in 2014 and changes to be implemented for 2015 to the Fee Schedule, Enrollment process, Documentation Guidelines for compliant reimbursement, PECOS, NPP Reimbursements, OIG target areas, ABN form updates, Medicare MSP Standards and much more.

 

Additional changes :

HEDIS 2015

PQRS 2015

***Expecting a major change in CPT to accommodate ICD-10.

 

AccuChecker puts all these resources at your fingertips. AccuChecker OnLine is an Internet database subscription service with procedures, diagnoses (ICD-9 and ICD-10) Medicare fee schedules using RBRVS tables and coding techniques.

 

www.accuchecker.com 

For more details, a Free Trial or Webinar call: 305-227-2383  or 1-877-938-9311

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Outsourcing Medical Billing

Physicians have to prepare for these billing changes if they don’t want their reimbursements to get affected for the services rendered. It has become important for them to ensure that their billing department is aware and ready for these changes. 2014 is going to be a challenging year for practices due to billing changes, rollout of healthcare reforms and preparation for ICD-10. To ensure that these factors don’t affect your RCM, you can outsource your billing requirements to a billing company.

HPP Management Group, Corp., is a reputed billing company, helping practices sail through billing and coding complexities. The well-trained, experienced team of coders and billers at HPP are apprised of the medical billing changes and updates in the healthcare industry. They are proficient in ensuring timely reimbursements with the help of latest technology.

HPP Management Group, Corp., works with the aim to maximize revenue and minimize claims denials. By outsourcing billing requirements to HPP, providers can reduce practice costs and eliminate their worries about investing in hiring staff, training and technology upgrades. Outsourcing also offers enough time to providers for concentrating on the provision of patient care.

Benefits of Outsourcing Medical Billing:

 

·         Timely claims submission

·         Denial management

·         Follow-up

·         Error-free coding and billing

·         HIPAA-compliance

·         HEDIS Proficient

·         PQRS (P4P) Proficient

 

 

HPP Management Group, Corp. the titled-holder of Health Plans Path, Corp (HPP) and also the developers of the AccuChecker Product Line is a group of healthcare consultants servicing physicians and payers since 1983. 

The HPP consultants have contributed to healthcare providers in many ways: 

The Management Group has represented physicians in over 500 Medicare and Medicaid audits of overpayment assessments and has recovered millions of dollars for our clients. The knowledge acquired in the audits served as the basis to develop the AccuChecker Product Line. 

Our team has conducted practice evaluations resulting in the implementation of successful solutions and businesses expansions as well as creating plans of corrections whenever needed. 

Our consultants have presented coding and reimbursement seminars to physicians practices across the nation and have conducted workshop on claims adjudications and claims scrubbing techniques to payers, TPAs, MSO and IPA organizations.

 

The Health Plans Path, Corp. (HPP) division has been involved for the last ten (10) years in managing Medicare and Medicaid HMO Risk Management Operations. 

During the last twenty (20) years the HPP team has been developing the AccuChecker Product Line – coding and reimbursement solutions to everyone dealing in preparation and submission of healthcare claims to the ones adjudicating and paying claims for the medical services rendered to patients.

 

Now the HPP Management Group is moving into the new frontier in healthcare reimbursement the Pay-for-Performance (P4P) alternative, the new way how healthcare providers receive their compensation where HEDIS, PQRS and other reporting measures systems become intrinsic modules of our software reimbursement applications.

 

 

Today the AccuChecker Product Line is recognized as:

“The Complete Tool for Medical Reimbursement” 

FOR MORE INFORMATION PLEASE CONTACT:

HPP Management Group, Corp.

Developers of the AccuChecker Product Line 

Phone: (305) 227-2383

Email: sales@accuchecker.com

Website: http://www.accuchecker.com

 

 

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Coding for Reimbursement

www.accuchecker.com

Coding for Reimbursement and Compliance 

 

Ø Start dual coding now to train your team and gather ICD-10 data for analysis.

Ø Improve accuracy, efficiency, and patient care processes

Ø Identify insufficient documentation while coding now in ICD-9 to identify the gaps ahead in ICD-10.

Ø Translate codes on claims, learning as you work what you will need for ICD-10.

Ø P4P   -  PQRS

Ø HEDIS

Ø CCI

Ø Local and National Medical Policy

Ø OnLine Support

 

HPP Management Group, Corp. the titled-holder of Health Plans Path, Corp (HPP) and also the developers of the AccuChecker Product Line is a group of healthcare consultants servicing physicians and payers since 1983.

 

http://www.accuchecker.com/AboutUs.aspx

 

For more details, a Free Trial or Webinar call : 305-227-2383  or 1-877-938-9311

  

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Managing Coding & Reimbursement Challenges

Managing Coding & Reimbursement Challenges

 

As any physician will attest, no one wants to leave money on the table or be accused of submitting incorrect claims. And yet every year, medical practices are faced with the daunting task of understanding the newest coding and billing rules, many fail to educate themselves on the new guidelines. The result: lower revenue potential, increased denials and greater operating/administrative costs for the practice.

Adding to this substantial challenge is the scheduled implementation of ICD-10-CM diagnostic codes. The delayed implementation of ICD-10 underscores the magnitude of change and the amount of preparation required for an efficient transition. Furthermore,  practices are having to implement HEDIS and PQRS (P4P) Measurements to meet Quality of Care Regulations.

 

To take the guesswork out of this complex system and lead reimbursement teams in a smooth and effective changeover to ICD-10, AccuChecker Online offers an Internet database subscription service that covers:  

·         Procedures – CPT, Category II and HCPCS codes.

·         Diagnoses codes (ICD-9-CM, ICD-10-CM and ICD-10-PCS).

·         Converter of ICD9 to ICD10.

·         Medicare fee schedules including OPPS rates in radiology.

·         Coding techniques like:

o   Corrective Coding Initiative (CCI)

o   Medical Necessity - procedures matching diagnoses.

o   Medicare’s LCD and NCD.

o   Surgical modifiers outlining coding guidelines.

o   Global period for surgical services.

 

New For 2014:

HEDIS Module

PQRS Module 

AccuChecker OnLine CLASSIC is available in two (2) versions:

State Version - Fee Schedules for the State ONLY.

National Version - Fee Schedules for the entire nation –for each zip code.

 

[ HEDIS and PQRS are separate modules ]

 

The HPP-AccuChecker Management Team developers of the AccuChecker Product Line is moving into the new frontier in healthcare reimbursement the Pay-for-Performance (P4P) alternative, the new way how healthcare providers receive their compensation, where HEDIS, PQRS and other reporting systems become intrinsic modules of our software reimbursement applications.

 We are committed to keep our customer base ahead of the game and to assist our clients in maximizing the compensation that they deserve for their efforts. 

 

www.accuchecker.com

 

For more details, a Free Trial or Webinar call : 305-227-2383  or 1-877-938-9311

 

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Physician Coding and Reimbursement

Physician Coding and Reimbursement

Physician reimbursement and the coding to support it are critically important to the sustained health of any physician's practice.

Physicians can bill or code for a number of different types of patient encounters. The most common non-procedural encounters are evaluation and management services, or E & M, codes and include outpatient activities such as office/outpatient visits, outpatient consultations, inpatient hospital visits, inpatient consultations, and management of patients in observation or critical case status.

Once a procedure or service receives a code, it needs to be valued for reimbursement purposes. Prior to 1992, physicians were reimbursed based on “usual, customary, and reasonable charges” (UCR). UCRs were based on the physician's most frequent charge for the service (usual), the average charge for that service in the area (customary), and the actual charge for the service (reasonable).

Today, physicians are faced with additional guidelines and regulations. Again, affecting how a provider is reimbursed. Today’s physician must understand :

·         HEDIS

·         Meaningful Use

·         Quality Measures

·         P4P – PQRS

 

Additional changes :   ICD-10 and Changes to CPT to accommodate the ICD-10

 

How does a physician keep up with all the changes in Coding and Reimbursement ?

 

The AccuChecker OnLine  is a comprehensive database with:

 

Procedures – CPT, Category II and HCPCS codes.

Diagnoses codes (ICD-9-CM, ICD-10-CM and ICD-10-PCS).

Converter of ICD9 to ICD10.

Medicare fee schedules including OPPS rates in radiology.

Coding techniques like:

 

     Corrective Coding Initiative (CCI)

     Medical Necessity - procedures matching diagnoses.

     Medicare’s LCD and NCD.

     Surgical modifiers outlining coding guidelines.

     Global period for surgical services.  

 

AccuChecker OnLine  is available in two (2) versions:

 

·         State Version - Fee Schedules for the State ONLY.

·         National Version - Fee Schedules for the entire nation –for each zip code.

 

The annual subscription for AccuChecker OnLine :

 

·         State Version - $299.00

·         National Version - $399.00

 

 

AccuChecker the ONE tool to manage your Coding and Reimbursement

   

www.accuchecker.com

  

Call for more details : 305-227-2383   or   1-877-938-9311

Call for your    Free Trial  or Webinar

  

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