Wednesday, March 31, 2010
This process of sending the charges to the patient's Insurance Company is called Filing Claims.
A service performed by the physician and entered in the system is called Charge but when the same charge is filed to that patient's Insurance Company, it is called Claim.
Claims may be sent in two ways:
Electronic claims are sent in ANSI/NSF Format. Paper claims are sent in CMS Forms-1500
Tuesday, March 30, 2010
ANSI- American National Standards Institute (ANSI) - A national voluntary organization of firms and private individuals who develop industry standards used in a wide variety of business applications.
National Standard Format (NSF) - Also known as “flat file” format.
It is one of the two standardized electronic formats that are currently accepted by Medicare.
When the patient visits the doctor for the first time, the following steps will be followed:
Documents submitted by a new patient at the front office
1.Patient demographics details.
2.Guarantor & employer details.
3.Insurance details + insurance card copies.
4.Assignment of benefits (AOB)
5.Release of information (ROI)
Coding for services in healthcare is complicated and therefore trained individuals are preferred. Federal regulations and health insurance policies have contributed to the strong demand for experienced medical coders.
Medical Billing is the practice of submitting claims to Insurance companies or the United States government, specifically Medicare in order to receive payment for services provided to a patient by a doctor.
This process is typically performed in a series of steps where the doctor examines a patient who is sick or provides other services. Depending on the service provided and the examination done, the doctor creates or updates the patient's medical record. This record will record the things that the patient noted to the doctor regarding illnesses or lifestyle. These form the basis for the diagnosis (may be multiple) that is referenced by the doctor as the basis for treatment.
The treatment, along with the diagnosis, and even the time spent with the patient all can be combined to determine the level of service or procedures that were provided to a patient. The doctor then either provides this information to a medical coder (A certified professional coder is known as a CPC.) or may do the coding himself. Next a billing record, either paper (usually a standardized form called an CMS) or electronic, is generated with the information, including various diagnoses identified by using numbers from the current ICD-9 manual.
This billing record is then submitted either to a clearing house that acts as an intermediary for the information (this is typical for electronic records) or directly to the insurance company.
Medicare physician fee schedule - Quick overview
covered services and their payment rates. Physicians’ services include the following:
* Office visits;
* Surgical procedures;
* Anesthesia services; and
* A range of other diagnostic and therapeutic services.
Medicare Physician Fee Schedule Payment Rates
Payment rates for an individual service are based on
1) Relative Value Units (RVU)
2) Conversion Factor (CF)
3) Geographic Practice Cost Indices (GPCI)
Medicare Physician Fee Schedule Payment Rates Formula
The Medicare PFS payment rates formula is shown below:
[(Work RVU x Work GPCI) + (PE RVU x PE GPCI) +
(MP RVU x MP GPCI)] x CF
Medicare fee schedule download