The service offered by these companies serves as the key for a doctor, or any healthcare provider for that matter, to get paid. The healthcare industry in America is alive and well, but in spite of this, many doctors and other healthcare providers dont have any idea how to get themselves paid quickly and efficiently. The answer, of course, lies in insurance. And how are insurance claimed? This is where medical billing companies come in.
Medical billing companies are the ones who would submit claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The process is basically the same for most insurance companies, regardless of whether they are a private company or a government-owned one.
The Billing Process
Essentially, the first step to jumpstart the whole billing process is the patients office visit. The healthcare provider will see the patient, diagnose his illness, and suggest treatment for such. Afterwards, depending on the service provided and the examination, the doctor then creates or updates the patients medical record. This record contains the summary of each of the patients visit, including details about treatment and demographic information related to the patient.
When you combine the treatment, diagnosis, and duration of service, this forms the procedure code, determined for usage in the billing of insurance. The doctor can of course take care of claims processing himself. However, the work can become tedious, especially when he should be focusing more on his healthcare practice than on insurance. Hence, the medical billing companies shoulder the burden for him.
The medical billing companies will use the information provided by the doctor to formulate the billing record. This record is generated manually or through the use of a software program. Often, the companies generate the billing record electronically. However, there are some that also produce hard copies as well (usually on a standardized form called an HCFA). This form includes the various diagnoses identified by numbers from the current ICD-9 manual.
It is the medical billing companies who will submit this billing record or claim to a clearinghouse. The clearinghouse acts as an intermediary for the information. Typically, when electronic billing is used, the medical billing companies must send their records to the clearinghouse.
Sometimes though, the record may also be sent directly to the insurance company. This is to ensure that everything is processed as efficiently as possible.
Doctors depend on medical billing companies for the money they get for the services they rendered. They can hardly find time to process everything themselves. The services offered are a great help in reducing the things they would have to worry about.
Clean Claim Laws are currently in place in every state. The assistance provided by the laws ranges from states like South Dakota which has no economic penalty to Texas where the payer sometimes is required to pay billed charges The fundamental concept behind Clean Claim Laws is that insurance companies must respond to a clean claim within a given period (typically 30 days for electronic claims). Systematic utilization of these laws will allow a medical billing service or medical practice to significantly accelerate and increase collections. In order to take advantage of the clean claim law one must have a monitoring system built into your medical billing process that identifies: 1. Which payers must abide by the clean a claim law (the laws do not apply to all payers), 2. The date your practice initially submits each medical claim; 3. Events that stop the clean claim clock (e.g., an information request from the payer), 4. When your practice has taken actions in response to payer requests; 5. The date from the payer's communication about the final disposition of the claim. The design and implementation of the system and reporting can be challenging, but it can pay huge dividends in terms of the penalties from payers and in the way in which you will make payers take notice of your claims next time. You may actually find, as have other aggressive users of the clean claim law, that you will receive calls from payers assuring you they will process your claims quickly and asking you to please stop submitting complaints. If you would like to better understand the benefits of implementing a Clean Claim Law tracking system before investing the time and energy into the design and implementation of the system, then run a pilot. Identify a payer that is consistently in violation of the Clean Claim Law. Select 30 to 50 claims from this payer and manually track all of the items outlined above. Once you have some violations, file a report following your state's guidelines. This process will allow you to better understand what will be required to make such a system a permanent part of your medical billing and see the potential benefit to your practice. Copyright 2006 by Carl Mays II
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Both T J Madigan & Carl Mays Ii are contributors for EditorialToday. The above articles have been edited for relevancy and timeliness. All write-ups, reviews, tips and guides published by EditorialToday.com and its partners or affiliates are for informational purposes only. They should not be used for any legal or any other type of advice. We do not endorse any author, contributor, writer or article posted by our team.