What is the Quality: Quality is conformance of
requirements.
(1) Quality of a Product depends on the user/customer.
ISO – International Organization for
standardization
ISO 9001-2008 (Quality Management System)
Principles of CMS
1. Document
2. Implement
3. Maintain
4. Continual Implement
1. What is Medical Billing?
Medical Billing is the business of
getting healthcare providers paid.
è It’s means mediator between providers
2. US social system – Social Security Number (SSN)
This is a 9 unique digit number give by
the federal Government social security office for the purpose of identification
and to maintain a portfolio of a person.
Format is – (3-2-4) 123-xx-xxxx
è In US phone format is 3-3-4 =
808-206-1234
è 
In US zip code
format is 5 – 4
In US zip code
format is 5 – 4 |
Area Code Optional (Post Box No)
Telephone Numbers or fax Numbers
American Telephone #s and fax #s are 10 digit
numbers
Format 212-323-9847, 800-258-6211
Note – The first 3 digits represents to area code
American Name Format:
All Americans have a “First Name” and “Last Name”.
The last name denotes their family name/surname.
They have a middle name but this is optional.
Ex: Brad Anthony Pitt is denoted by as Pitt, Brad A
Times Zones: We have 6 US time zones,
USA is a huge landmarks and is therefore divided in
6 timezones
è EST – Eastern Standard Time
è CST – Central Standard Time
è MST – Mountain Standard Time
è PST – Pacific Standard Time
è AST – Alaskan Standard Time
è HST – Hawain Standard Time
CLAIMS FORMS
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CMS 1500 UB04
Used for Physician Billing Used for Hospital Billing
33 Blocks 37 Blocks
(What are the treatments are provided)
Participants in the US health care system
1. Patients – New Patients – establishment Payments
2. Providers
3. Payers/Insurance Companies/Carriers
Providers
 |
INDIVIDUAL FACILITY
1. Primary care Physician (PCP) 1.
Hospital
2. Speciality Care Physician (SCP) 2.
Ambulatory Surgery Center
3. Skilled Nursing
Facility
4. Home health
(1) What is the reimbursement System?
Patient ->
Doctors/Facility -> Medical Billing Company -> Insurance Company
Payments payment & EOB
Patient Name classified as a three
names
First Middle
Last
(1) Three names without comma then it
is in order First Middle and Last
Ex: Carol V Smith
(2) Comma is there then name before
comma is last and name after comma is first name.
Ex: Smith, Carol V
(3) Middle name always followed by
first name
(4) Female Name never used as last name
(5) Last name is common name of the
family (or) family name
Prefixes & Suffixes
è
Prefix must always be entered with the
first name
è
Suffix must always be entered with the
last name
Ex: Prefixes – Dr, Mr, Mrs.,
Suffiexs – Jr., Sr., II, III
(1) Medical Billing acts as a bridge
between providers and insurance company.
(2) US healthcare revolves around
patient, providers, payers
BILLING CYCLE
(Preregistration (ROI, AOB) Voice
Patient Pre-registration Encounter Medical Transcription
(Illness,
Injurious) Files
Scanned
Image of Demo files
Demo
Entry Diseases
1. Diagnosis Codes Coding
(Patient Details 2. Procedure codes
Name, Insurance)
Demo
Sheets
Charge
Description Master (CDM)
Collections
Charge Posting |
Denial – Fail to pass the payments
(Medical Billing)
Accounts Receivables Claim Form
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 |
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Cash Posting/Correspondence
Insurance Company Clearing House
Individual
Providers
(1) Primary Care Physician (PCP)
è Trained in general medical care
è Treat routine Problems
(2) Specialty Care Physician (SCP)
è
Has more Advanced medical training than
primary care physician
è
It certified to practice in a certain
field of medicine.
Ex: Cardiologist,
Radiologist, Dentist etc.,
Billing Amount (T/C Total Charges) $
100
Allowed Amount $ 80
Of Allowed Amount $ 80 %
Co Insurance $ 16
Contractual Adjustment – The contract between the insurer and provider
Billed Amount $ 500.00 Contractual Adjustment - $ 250.00
Allowed Amount $ 250.00
Based on the allowed amount 80% then pay remains 20% patient has to pay
to insurance company.
è Patient has to pay 50 (Co Insurance)
è 80% of Allowed Amount 200 Pays insurance company.
PATIENT RESPONSIBILITIES
Co Insurance :
After Insurance Pays
Co – Pay : At the time
of Service
Non Covered Service :
You can bill secondary
Deductible (Yearly) :
At the time of buying policy (It changes every year)
Premium :
Monthly, Quarterly
It not pay policy gets termed not to be achieved.
(Providers IDs/Qualifier)
TIN – Tax Identification Number – It issued by federal Government.
Format: 3-2-4 / 2-7
PIN – Provider Identification Number. Issued by Insurance Company to
participations providers.
There is no format
differ from payer to payer.
NPI – National Provider Identification - Issued by CMS & HIPPA makes
this mandated.
10 digits single character numeric character.
* The CPT code and HCPCS code this two comes under procedure codes.
Supplemented Plan – Primary Insurance covered may or details if it is
not paid remaining one secondary insurance with covered.
1. Supplement plan Covered a Patient responsibility
2. Supplement plan also acts as secondary insurance.
Ex: Co-pay or Co insurance
B. A - $ 600.00 Billed
Amount
C. A - $ 200.00 Contractual
Adjustment
A. A - $ 400.00 Allowed
Amount
P. A - $ 320.00 Payment
Amount
PTR- 80.00 Patient
Responsibility
Participants
1. Fee Schedule
2. Capitation
3. Case Rate
4. Bundled (The
professional component technical component billed together on paid.
Non – Participants (or) Non-Par
PPO/POS
HOSPITALS |
|
Acute Care
Hospitals Chronic
Care Hospitals
Intensive care on short term basis Long
term care
Could include on overnight stay Care not
as a intensive
Ambulatory Surgery Center:
-> Ambulatory surgery is surgery that not require on overnight stays.
-> It is also called day surgery, same day surgery (SDS)
Ex: Eye surgeries, and cataract, laparoscopic surgeries, ears, and
throat procedures.
Skilled nursing facility:
1. Primary providers in patient treatment
2. Lesser intensity than acute facility
3. Usually for long term basis
4. Less expansive
5. Visiting doctor or a doctor on call
(SNF – Skilled Nursing Facility)
UCR – Usual customary & Reasonable rate
Home Health:-
* Providers service at home
* According to be a writer plan of treatment signed by the patient’s
physician
* These services are provided at home for the dispelled old &
injured
* Providers medical, nursing, pathology, or Therapeutic treatment and
assistance with essential activities of daily lungs.
Hospice:-
* For terminally ill person (Patient with a life expectancy of 6 months
or less)
* Treatment for terminal illness stops during hospice care
* Only symptom management end treatment for any other illness is
provided
Ex:- Cancer, HIV, ESRD(End Stage Renal Disease)
Payer/Insurer/Carrier
Health Insurance:
- Health insurance covers inpatient & outpatient services
- The person covered by health insurance – insured/enrollee
- The spouse & children of the insured – covered/dependents
Types of Payers
Payers
 |
Federal Private Liability
Medicare BCBS Auto Liability
Medicaid Managed care Organization Workers Compensation
Tricare Commercial Insurance 
Champva
Each Insurance Plan Has:-
-
Service covered
-
Non-Covered Services
-
Premium
-
Patient responsibility on the bill
-
Provider network
Insurance Policy Sample
The health insurance card will have the
following information
- Identification Number (Policy Number)
- Group Number
- Plan Type
- Policy Holder (Subscriber, Insured,
beneficiary)
- Co payment info
- Co insurance info
- Deductible info
Medicare:-
- Nations largest insurance program
- CMS administers Medicare
- Medicare ID’s are called as HIC #s
(Health Insurance Claim #s) (Format SSN)
- HIC # format is 10 characters (9
digits + alpha)
Ex: 123456789A (Policy Holder)
Medicare Eligibility:
- Persons 65 years and over + 10 years
TAX
- Under 65 but have certain disability
- ESRD – End Stage Renal Disease
PART A (HOSPITAL INSURANCE)
|
PART B (MUST BE PURCHASED)
|
1. Receive Part A automatically.
2.
Yearly deductible for the year 2011 is $ 1132.00
3.
Need not Purchase
4.
Covers inpatient hospital expenses
5.
Pay for hospital, SNF, hospice care
|
1.
Yearly deductible for the year 2011 is $ 162.00
2.
Covers the outpatient healthcare
3.
To purchase Part B one should have Part A coverage
->
Pay for
* Doctor’s Services
* Outpatient hospital services
*
DME/Consultation/Office visit
|
Part A: Hospital
Billing/Charges/Inpatient
Part B: O/P healthcare –Medical
Billing/Physical Billing
Part C: Medicare advantage Plan
Part D: Prescriptions on drugs
Medicare Secondary Payers (MSP)
Medicare secondary payers is the term
used when it is not responsible for paying first
* MCR acts as secondary payers for the
following
- Group health plans
- Most of the SGHP (Smaller Group
Health plan)
- For LGHP & EGHP (Large &
Endorsee group health plan)
- Black lung program (who are working
in cold mines)
- Workers compensation plans.
- Auto Liability plans Ex:- No-fault
insurance
- Champva
- Champus (uniform Services)
Railroad medicare:-
It’s a medicare program offered to
retired railway employees who are above 65.
(Format alpha + SSN)
Medicaid:-
1. A Federal State Program
2. for individuals and families with
low income & resources
3. Each state operates its own Medicaid
program, with certain federal Guidelines
4. There is no patient responsibility
in most cases
5 But in cases “spend down charges
& co-pay” are applied
6. Policy needs to be renewed monthly
7. Medicaid is always the payers of
last resort.
Champus/Tricare:-
1. Is provided to military personnel
and their dependents.
2. Eligible Beneficiaries must be
listed in the DEERS.
(Defense Enrollment Eligibility reporting system)
Tricare Plans:
- Tricare Primary – for active military
persons
- Tricare Standard – for retired
military persons
- Tricare Extra – for retired military
persons
- Tricare for life – for military &
their spouse who have Medicare part A&B.
Champva:-
The civiler Health and medical program
of the department of Veterans administrations.
Eligibility: The spouse or child of a
veteran who has been rated permanently and totally disabled for a service –
connected disability.
The servicing spouse (or) children of a
veteran who died from a service connected disability
Commercial Plans: - Indemnity Plan
- Managed care organizations
- Blue Cross blue shield
EOB
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DOS
|
CPT Code
|
B.A
|
A.A
|
C.A
|
P.A
|
6/6/2013
|
99801
|
$ 600.00
|
$ 468.75
|
$ 131.25
|
$ 337.50
|
6/7/2013
|
99802
|
$ 400.00
|
$ 312.50
|
$ 87.50
|
$ 225.00
|
6/8/2013
|
99803
|
$ 1,200.00
|
$ 937.50
|
$ 262.50
|
$ 675.00
|
6/9/2013
|
99804
|
$ 1,000.00
|
$ 781.25
|
$ 218.75
|
$ 562.50
|
$ 3,200.00
|
$ 2,500.00
|
$ 700.00
|
$ 1,800.00
|
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= B.A – A.A = C.A
|
|
PATIENT RESPONSIBILITY
|
||||||
DOS
|
CPT
|
BA
|
AA
|
CA
|
PTR
|
PA
|
6/1/2013
|
99801
|
$ 600.00
|
$ 480.00
|
$ 120.00
|
$ 25.00
|
$ 335.00
|
6/2/2013
|
99802
|
$ 400.00
|
$ 320.00
|
$ 80.00
|
$ 240.00
|
|
$ 1,000.00
|
$ 800.00
|
$ 200.00
|
$ 575.00
|
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Commercial Payers
* These are private for profit
companies
* They offer more than just health
insurance
* They may also offer auto, life, home
etc.,
Ex: Aetna, MCO, BCBS, Cigna, UHC etc.,
Indemnity Plan (Traditional or commercial)
In
this plan insurance company usually pays percentage of the allowed amount.
Patient is responsible for paying the remaining co percent.
Managed care Organizations
It
attempts to “manage a person’s care” by offering tailor over plans.
Common types of managed care plans:-
1. Health maintenance organizations
(HMO) plans
2. Preferred provider organizations
(PPO) plans
3. Point of service organizations (POS)
plans
Health Maintenance Organizations -
Covers only in network providers
1. Services by out of network providers
become the patient’s responsibility to pay the entire cost of the service.
2. When the physician has a contract
with on HMO plan is considered capitates
3. A patient must first visit a primary
care physician
4. The PCP may refer (referral) that
patient to a specialist with in the network if necessary
Preferred Provider Organizations
1. Consists of a network of providers
larger than the networks in an HMO
* There is no role of a PCP
* Covers both in network/out of network
* Patient’s responsibility on a bill
would be higher if he goes out of network
Point of service Organization
1. Covers both in network providers
(like an HMO), or out of network providers (like on PPO)
2. Mandatory to meet PCP only when
using in network providers
3. No role of PCP when using out of
network providers
4. Patient’s responsibility on a bill
would be higher if he goes out of network.
MCO PLANS
|
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Plans
|
Role of PCP and Referral
|
In network Providers
|
Out of network Providers
|
HMO
|
√
|
√
|
|
PPO
|
√
|
√
|
|
POS
|
√
|
√
|
√
|
Blue Cross Blue Shield
1. The Blue Cross and Blue Shield
association provides health care coverage for nearly 100 million people
2. Health coverage is available in all
50 states, the District of Columbia and in Pverto Rico
3. BCBS – IDs – both alpha and numeric
characters, 6 to 17 digits, including the alpha prefix
Ex: XYZ1234567891 XYZ represents to State code
(The alpha prefix determines the state
in which the patient looks his insurance)
BCBS federal employee plan: (not a
Govt., employee buys a plan) for all the federal employees
ID format – “R” followed by 8 digits.
Ex: R123456789
Home plan: It usually refers to the
plan that is taken by the patient in his/her state where the patient resides
& pays premium.
Local Plan: It usually refers to the
plan/State in which the patient takes treatment besides his/her home plan.
Liability Insurance – Auto Liability
- Bodily injury to you and others
- Damage to someone else’s car or
properties
- The cost to repair your vehicles that
are damaged in an accident
- The cost to rent a replacement
vehicles while your damaged vehicles is being repaired.
No- Fault:-
- The drivers involved would submit a
claim to their own auto insurance companies and receive compensation from them.
- No fault insurance is offered in no
fault states
- Each state own coverage stipulations
and resolutions
Worker’s Compensations
1. This plan covers only work related
problems
2. No premiums for employees
3. No patient responsibility
4. The policy in the name of the employer
5. Each injury reported by a employer
got a claim #s
6. Claims to be submitted along with
medical records
7. Role of an “Adjuster” (Investigation
Officer)
Place of service codes
- Place of service is the location
where the patient received treatment.
Some of the most common place of
services (POS)
Codes are 11. Office
21.
Inpatient
22.
Outpatient
24.
Ambulatory Surgery Center
31.
Skilled Nursing Facility
34.
Hospice
Types of Services codes
Two
digit codes that represent the type of care gives to the patient some of the
type of services codes are listed below:-
01 Medicare
02 Surgeries
03 Consultations
04 Diagnostic X-Ray
05 Diagnostic LAN
06 Radiation Therapies
07 Anesthesias
08 Surgical Assistance
09 Other Medical
10 Blood Charges
11 Used etc.,
Claim Submission
Manual Claim Submission – Each
submitted claim mu8st have an attachment for the claim to be considered for
payment.
Ex: Primary
EOB attached
Medical
Records
Electronic
Claim Submission
Faster
reimbursement & reduced error rate
Formulas: -
Contractual Adjustment : Billed
Amount – Allowed Amount
Allowed Amount : Paid
Amount + Con insurance + Co Pay + Deductible
Billed Amount : C.A
– A.A
% of Allowed Amount : (Total
A.A/Total B.A*100)
% of Payment Amount : (Total
paid/Total A.A*100)
Providing
Insurance Companies
|
Non
Providing Insurance companies
|
1.
In network providers
2.
Participating Providers
3.
Contracted Providers
|
1.
Out of network Providers
2.
Non Participating Providers
3.
Non Contracted Providers
|