US Healthcare & Medical Billing

• Campus Training - GB & AR CURRICULUM (3 Months)

Introduction to US Healthcare & Medical Billing

• The healthcare industry provides services to treat patients with curative, preventive, rehabilitative, palliative, and elective care.
• Healthcare facilities are mainly owned and operated by the private sector.
• The government plays a significant role in the U.S. Healthcare system.
• Government-funded programs offer benefits to specific groups like children, the elderly, and the disabled.
• Laws regulate various aspects of healthcare delivery.

The Need for Health Insurance

• Health insurance protects against very high medical expenses.
• It covers routine visits to a physician for preventive care, not just emergencies.
• Health insurance helps prevent exploitation by healthcare providers.
• Health insurance improves the overall quality of care.
• Health insurance increases access to healthcare for individuals from different backgrounds.

What is medical billing?

• Medical billing is the process of submitting healthcare claims to insurance companies to get paid for medical services.
• Medical billers work between patients, healthcare providers, and insurance companies to arrange payments for healthcare services.
• Billers collect patient demographics, medical history, insurance coverage details, and service/procedure information.
• Billers need to review medical charts and insurance plans to verify coverage before generating and submitting claims.

Medical billing process

• The medical billing process is divided into front-end and back-end stages.
• Front-end billing happens before the patient sees the doctor and involves front-office staff activities related to patient interaction.
• Back-end billing occurs after the patient visit, including medical coding, charge entry, claim generation, scrubbing, and submission.

Participants in US Healthcare

• The three primary parties in U.S. healthcare transactions are the Patient, Provider, and Payer.
• A patient is any recipient of healthcare services.
• A provider offers healthcare services to individuals, families, or communities.
• An Individual Healthcare provider is a healthcare professional or an allied health professional.
• Healthcare facilities include hospitals, clinics, primary care centers, and other service delivery points.

Healthcare Reimbursement System

• Healthcare reimbursement is the payment a healthcare provider receives for providing a medical service.

Revenue Cycle Management

• Revenue is the income a healthcare provider generates for services or goods.
• Revenue Cycle Management (RCM) is the entire medical billing process from start to finish.
• Inefficiencies, errors, or backlogs in the revenue cycle can delay or prevent payment to the provider.

Patient Scheduling

• Patient scheduling is the process of setting a time and date for a patient to meet with the provider.
• Effective scheduling reduces dissatisfaction among providers, staff, and patients.
• There are various methods for scheduling patient visits, including appointment systems, individual/group appointments, and walk-in clinics.

Registration

• Registration involves collecting a patient's demographic details at the front desk when they visit the facility.
• Demographic details typically fall into four categories: patient, guarantor, employer, and insurance information.
• Facilities use registration forms to collect demographic data.
• Accuracy in the collected details is essential for ensuring clean claims are billed.
• Front desk staff registers the patient in the provider's software to create a unique account or encounter number.

Insurance eligibility verification

• Front-office staff verifies a patient's insurance coverage to ensure payment for services.
• Verification can be done by phone or using an electronic eligibility verification tool.
• The process confirms eligibility dates, coinsurance, copay, deductible, and plan benefits for the specific specialty and place of service.
• Verification details fall into three categories: patient, plan/policy, and claim submission details.

Point of Service Collections

• Point-of-service (POS) collections involve collecting the patient's portion of the bill before service is provided, either at check-in or checkout.
• Collecting a copay at the time of service is an example of POS collection.
• POS collections are key to medical billing as they reduce patient balance follow-up expenses and help avoid bad debt/write-offs.

Documentation of Visit

• Documentation includes patient history, encounter notes, diagnosis codes, follow-up information, orders, prescriptions, assessments, and labs.
• Each patient encounter documentation should include the reason for the encounter and relevant history.
• It also includes an appropriate history and physical exam in relation to the patient's chief complaint.
• Documentation contains review of lab, x-ray data, and other ancillary services where appropriate.

Medical Management

• Medical services are provided to the patient during this phase.
• Services may include consultation, prescription of medicine, primary care, surgeries, elective services, rehabilitative services, and durable medical equipment.

Encounter form generation

• An encounter form, also known as a superbill or fee ticket, is generated for each patient encounter.
• Printed with patient demographics, it lists common services with medical codes, and has space for clinicians to note diagnoses.
• Front-end staff generates the form, which is used to communicate service information.
• The provider marks services performed and signs the form to attest they can be billed.
• Encounter forms are often electronic in practices using EHR and practice management systems.

Medical Transcription

• Medical transcriptionists review medical reports for accuracy.
• These healthcare documentation specialists convert voice recordings from healthcare workers into formal reports using electronic devices.
• The medical record is the legal record documenting healthcare services provided to a patient.

Medical Coding

• Once services are rendered, they are captured on an encounter form or superbill and attached to the patient's medical record.
• The record is then routed to a coding specialist.
• Diagnosis codes and procedure codes are used to denote the diagnosis, procedure, and services rendered.

Charge entry

• The encounter form tells charge entry staff what services and procedures were performed.
• Charge entry staff enters these charges and any patient payments into the practice management system.
• Charge entry also involves confirming all charges and receipts were added when reconciling patient charges, usually at the end of the day.

Claim Checking and Error Resolution

• Claims are reviewed electronically for missing information or errors before submission.
• Flagging claims allows providers to submit "clean claims," which reduces errors and costs.
• Most practice management systems have pre-bill review features to help submit clean claims.
• Many systems have options for customization.

Clearing House

• A clearing house receives claims from providers, checks claims for technical errors and sends claims to the correct insurance company.
• Claims sent to a clearing house are checked for syntax errors; errors are returned to the provider for correction.
• Error-free claims are securely transmitted to the payer.
• The clearing house generates reports, including the number of claims received/sent and claims sent back for corrections.

Claim Submission

• Healthcare providers submit claims in two formats: electronic and paper.
• Electronic claims are sent electronically to the insurance company, and the provider determines how to submit attachments.
• Paper claims are printed and mailed to insurance companies.
• Reasons to send paper claims are: provider's inability to send electronically, if the insurance specifically requires a paper claim, and if the claim needs supporting documentation.

Claim Adjudication

• Claim adjudication is when the payer examines claims and decides whether to pay or deny, based on contracts.
• Adjudication verifies if the claim has the necessary information, is not a duplicate, follows payer rules and procedures, has covered benefits, and is medically necessary.

Payment

• Insurance companies pay via bank check for paper claims or electronic fund transfer (EFT) for electronic claims.

Denials

• If a claim is denied, the Explanation of Benefits (EOB) provides the reason and resubmission/appeal instructions.
• The provider must make necessary corrections and resubmit/appeal the denied claim for reimbursement.

Payment Posting

• Payment posting is entering payment details from the EOB/ERA and payment checks into the patient accounting system.
• Understanding charges, EOBs, and ERAs is important in the payment posting process.

EOB vs. ERA

• An Explanation of Benefits (EOB) details how a claim was adjudicated/reimbursed
• An EOB typically includes: patient details, service details, claim details, payment/denial details.
• Electronic Remittance Advice (ERA) contains the same information as an EOB but is submitted electronically.
• ERAs are typically received faster than EOBs.

Denial Management

• Denials should be addressed quickly.
• Remittance advice provides denial codes and explanations.
• Claims should be reviewed to see if additional info is needed, errors need to be corrected, or to appeal.
• Appeals involve medical billers working with medical coders, preparing appeal letters, and refiling claims.

A/R Follow-up and Appeals

• Accounts Receivable (AR) follow-up is responsible for managing denied/rejected claims and refiling them.
• The medical billing appeals process is used when the provider or patient disagrees with denied reimbursement.

Patient Statement

• A patient statement is a medical bill sent to patients via mail, email, or text.
• A clear statement helps facilitate smooth transactions and promotes financial clarity.