Medical Billing: Oct 16, 2010

Saturday, October 16, 2010

Medicare

Medicare is the federal (national) health insurance program for Americans age 65 and older and for certain disabled Americans. If individual is eligible for Social Security or Railroad Retirement benefits and are age 65, he and his spouse automatically qualify for Medicare.

Medicare has two parts: hospital insurance, known as Part A, and supplementary medical insurance, known as Part B, which provides payments for doctors and related services and supplies ordered by the doctor. If individual is eligible for Medicare, Part A is free, but insured must pay a premium for Part B.

Medicare will pay for many of insured health care expenses, but not all of them. In particular, Medicare does not cover most nursing home care, long-term care services in the home, or prescription drugs. There are also special rules on when Medicare pays patient’s bills that apply if patient have employer group health insurance coverage through his own job or the employment of a spouse.

Medicare usually operates on a fee-for-service basis.
Some people who are covered by Medicare buy private insurance, called "Medigap" policies, to pay the medical bills that Medicare doesn't cover. Some Medigap policies cover Medicare's deductibles; most pay the coinsurance amount. Some also pay for health services not covered by Medicare. There are 10 standard plans from which individual can choose (some States may have fewer than 10.) If an individual buy a Medigap policy, he should make sure that he does not purchase more than one.

Workmen’s Compensation Insurance

This insurance policy protects the insured party from legal liabilities against injury or death of any of his employees who is a "workman" as defined by the Workmen's Compensation Act.

This insurance policy is necessary for every employer since it indemnifies him against his legal liability as an "employer" towards accidental or fatal injuries sustained by his work men during work.
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On extra payment of premium, medical, surgical and hospitalization expenses including transportation costs are also covered.
Liabilities that may arise owing to diseases mentioned in Section III (C) of Workmen's Compensation Act during the course of employment are also covered

Why Physicians go for Medical Billing Companies to do billing?

America has more than 3000 insurance companies, each with a number of plans. This posed a problem to the physicians. Every insurance company required the medical claims filed to them according to their own rules and formats. Also, when physicians sent out claims to these insurance companies the explanation of the diagnosis and the treatment, necessary to every claim, were voluminous and time consuming.

The forms and codes developed by Center for Medicare and Medicaid Services (CMS – formerly known as HealthCare Financing Administration HCFA) reduced the volume of the information to be transferred to the insurance companies but the volume was still considerable and required skill and time. The medical treatment performed still had to be encoded. These codes, with the patients’ demographic information, still had to be entered into specific medical billing software’s. This process was again time consuming and the extra personnel and infrastructure meant extra costs. They could not handle the volume and turned to specialist billing offices for assistance.

It was easier for a physician to source their non-medical, accounting work to a billing office so that he could concentrate on his practice. Thus the medical billing office became an intermediary between the physician and the insurance companies.

The billing office collects information relevant to the patients’ treatment from the physicians’ office. Using these codes and forms, the billing office bills the insurance companies and patients on behalf of the physicians. Until recently, medical billing was usually done by typing out and mailing claims to various insurance companies. Now the objective of the medical billing industry is to offer fast, efficient, and error-free claims processing using computers to log and transmit claims to the insurance companies.

Why you Need Health Insurance?

The United States does not have socialized medical care. If a person does not have health insurance coverage, he / she have to pay for health care out of their own finances at the time of service. This can run into many thousands of dollars for serious illnesses

One buy’s health insurance for the same reason one buy’s other kinds of insurance, to protect one self financially. With health insurance, an individual and their family are protected in case of any medical care that could be very expensive.

One cannot predict what his medical bills would be. In a good year, costs may be low but if he becomes ill, medical bills could be very high. If he has insurance, many of medical costs are covered by a third-party payer, not by the individual. A third-party payer can be an insurance company or, in some cases, it can be the employer.

Many people in the United States are enrolled in some sort of managed care plan. This is an organized way of both providing services and paying for them. Different types of managed care plans work differently and include preferred provider organizations (PPOs), health maintenance organizations (HMOs), point-of-service (POS) plans and fee-for-service plans.

Individuals enrolled in health care plans pay a monthly or quarterly fee as insurance for the time when they will need medical attention. At the time when a service is provided, the health insurance organization pays part or the entire fee, minimizing the amount an individual have to pay at the time of service.

Choosing the right insurance plan that best meets financial circumstances will depend on information like, whether an individual is married or single, have children or no children. Definitions of the health insurance terms used are included in the section called Understanding Health Insurance Terms.

What is Medical Coding?

Every Healthcare Provider that delivers a Service receives money for these services by filing a claim with patient’s Health Insurance Carrier. This is also referred as an encounter. An encounter is defined as “a face to face contact between a healthcare professional and a eligible beneficiary.”

Codes exist for all types of encounters, services, tests, treatments, and procedures provided in a Medical office, clinic or hospital
. Even patient complaints such as headaches, upset Stomach, etc have codes which consist of a set of numbers and a combination of set of numbers. The Combination of these codes tells the payer what was wrong with patient and what service was performed. This makes it easier to handle these claims and identify the provider on a predetermined basis.

Reason for the Visit /Encounter – Diagnosis Code
Service rendered - Procedure Code
Coding Systems:

The two major coding systems are

1. International Classification of Diseases – Clinical Modification – 9th Revision (ICD-9-CM)
2. Current Procedural Terminology (CPT)
CPT and ICD-9-CM are not the only coding systems. Here are few more coding systems that are used to code a variety of coding information:
1. CDT-3 codes
2. ABC codes
3. SNOMED codes
4. NDC codes
5. Home Healthcare (saba) codes
6. DRG systems.

What is a Claim?

A claim is a request made to the insurance company, by the billing office on behalf of the insured person or the physician, for reimbursement of services rendered by the physician. A claim is sent out on standardized forms that contain information regarding the patient, his insurance coverage, the physician, the diagnosis and the treatment. A claim is either mailed or electronically transmitted to an insurance company.

In a small family practice or suburban clinic this task may be simple and assigned to the medical assistant or nurse but in bigger practices and clinics this is the medical biller's job! When a physician treats a patient, the doctor’s office must file an insurance claim to get paid. This claim is usually filed on paper and sent by mail. These paper claims are notoriously slow, often taking 60-90 days or more for the doctor to get paid.

Now, these claims can be processed electronically, saving healthcare provider’s time and money. With electronic claims processing, payment time is drastically reduced to just 7 to 21 days on average. This dramatic improvement in cash flow is exactly why medical billing is in such demand. Physicians are constantly seeking remedies to their medical billing difficulties.

What are the problems faced by US providers or physicians?

Constantly US physicians face the problems of insurance coding & payment reimbursement on their insurance claims. Optimizing reimbursement is like trying to piece together a puzzle with a lot of pieces. Not only is there a lot of complexity, but change is continuously occurring. There are a number of important factors, few are outlined below.

1. Providers are using invalid, obsolete or deleted codes while submitting claims to respective insurance carriers.
2. The code and fees may be okay, but providers may be losing charge information, missing super bill fees or billing insurance carriers wrongly or irregularly.
3. The practice is not well-informed about current coding and billing issues.
4. The practice doesn't have and/or doesn't follow written policies and procedures which support the billing, coding and collections processes.
5. Not participating in Medicare may allow providers to bill higher fees to patients, but this may not be in the best interests of their practices.
6. Poor understanding of how insurance carriers work and ineffective strategies and systems for dealing with them.
7. The practice is not using forms and documents which are current.

In general, the basic tools needed by health care providers for optimizing reimbursement are:
1. A thorough understanding of the billing process and related terminology.
2. Procedure coding and diagnostic expertise.
3. A well-designed super bill.
4. A fee schedule based on relative values.
5. Current and accurate forms and documents.
6. Current reference materials (such as code books).
7. Written policies and procedures covering billing guidelines.

FFS, Also Called Traditional Indemnity

FFS coverage offers flexibility in exchange for higher out-of-pocket expenses, more paperwork, and higher premiums.

FFS advantages:
• Individual may choose your own doctors and hospitals.
• Individual may visit any specialist without getting permission from a primary care physician.

FFS disadvantages:
• There's typically a deductible (anywhere from $500 to $1,500) before the insurance company starts paying claims, and then doctors are reimbursed about 80 percent of the bill while patient pick up the remaining 20 percent.
• FFS plans pay only for "reasonable and customary" medical expenses. If patient’s doctor charges more than the average for the area, patient will have to pay the difference.

Tools of the Medical Billing

1.CPT Book – Procedural Coding

Medical services provided by physicians are identified using the AMA Current Procedure Terminology or CPT codes. The AMA CPT book provides descriptors for each of the 8,000 codes listed. Frequently there are additional instructions for code use in each section of the book. These CPT rules should be followed when choosing the correct code to describe the service provided

2.ICD-9-CM - Medical Diagnosis Coding

The ICD-9-CM coding system contains three "volumes" of coding information although the volumes come in one book. Volume 1 contains the diagnosis codes that every provider needs for billing. Volume 2 is an alphabetical index of Volume 1. Outpatient diagnostic or treatment centers, like physician offices, need only Volumes 1 and 2. Thus, books that contain only Volumes 1 and 2 are often referred to as physician, office, or outpatient editions.

Volume 3 contains procedure codes, not diagnosis codes. Volume 3 codes are used for billing inpatient hospital stays in the DRG system so books that contain Volume 3 are called hospital, payer, or inpatient editions

3.HCPCS – CPT Level II codes

HCPCS Level II codes are used to bill Medicare for supplies, materials, injections, DME, rehab, and other services.

4.NCCI Manual

National Correct Coding Initiative guide will help us code our service for reimbursement in compliance with CMS’s policies to prevent claim rejection, delays, and audits.

Medical Emergency

In an emergency, the first thing to remember is "911". This is the telephone number to call from anywhere in the United States for immediate, skilled medical attention. While it is wise to have other important numbers regarding medical assistance (individual’s personal doctor, poison control center, etc.) near telephone, in a genuine emergency it is imperative to dial 911 first. In such situations, time is the most important factor in preventing damage or even loss of life. The operator handling your "911" call will immediately dispense the necessary help, both in terms of sending an ambulance and in routing individual’s call to a counselor who will guide through the situation until the ambulance arrives.

Emergency medicine in the U.S. is very high quality. Ambulance attendants, or paramedics, are highly trained in dealing with trauma and making split-second decisions that save lives.

And many hospitals are equipped with trauma centers whose single purpose is handling emergency situations, including emergency surgery. In an emergency, individual will begin to receive treatment immediately and will be taken to the facility that can best handle the situation, whether it is a trauma center, a burn treatment center, a cardiac treatment center (heart attacks), a children's hospital or a general hospital. If an individual is conscious, or if there is a family member or a friend with the individual, they will be asked for the name of patient’s doctor, who will be summoned to the hospital to which patient is taken.

It is important to keep in mind that while emergency care in the U.S. is excellent, it is also expensive. There will be a fee for the ambulance, the emergency room, any medications administered, the services of doctors involved and any tests or special procedures involved. It is important never to hesitate when there is a genuine emergency but these services are not intended for situations where a call to your doctor or a visit to a walk-in clinic would be sufficient.

An additional note about "911": This number is also used in police emergencies, and therefore is not limited to medical situations. Any time an individual is in serious danger, witness an accident or a crime in progress, this number is called.

Showing newest posts with label PPO PLAN. Show older posts

PPO PLAN

PPO PLAN

PPOs give policyholders a financial incentive — reasonable co-payments (also called co-pays) — to stay within the group's network of practitioners.

PPO advantages:
• The standard co-payment is $10 for a routine office visit during regular hours.
• Individual may go to any specialist without permission, as long as the doctor participates in the network.

PPO disadvantages:
• If individual see an out-of-network doctor, he may have to pay the entire bill himself, and then submit it for reimbursement.
• Individual may have to pay a deductible if he chooses to go outside the network, or pay the difference between what network doctors vs. out-of-network doctor’s charge.

PATIENT DEMOGRAPHICS – AN OVERVIEW - 3

V. Insurance Information
This segment of face sheet contains all active insurance information of the patient. This segment includes primary, secondary, and/or tertiary insurance information. This segment is the most important field in patient demographic sheet. Information found in this field should always be the updated & correct one. If not, we would be submitting claims to incorrect insurance. Entry persons should always match this information with copy of insurance id cards. (if provided). This will reduce the risk of entering incorrect insurance information. Following information are found in this segment

1. Insurance Code/Name
2. Effective Date
3. Subscribers Name
4. Relationship Code
5. Pre-Certification/Pre-Authorization
6. Referral Number
7. Primary Insurance Group #
8. Primary Insurance Policy #
9. Date of Injury/Accident
10. Claim Number

1. Insurance Code/Name: This field is used to enter the insurance code or name of the coverage that the patient has. The insurance code is assigned by the Billing office for its internal purpose to reduce the PD entry time. Each Insurance company’s name, billing address, contact person, etc… are assigned a unique code. The entry person should be very careful while selecting the insurance code and should always verify the billing address with the given card copy or with the billing address given on the encounter form.
The Primary insurance name is printed in the 11c field and the Secondary insurance name is printed in the 9d field of the CMS-1500 claim form.
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Example:
Insurance: Medicare, Medicaid, Blue Cross, Blue Shield …

2. Effective Date: This field contains the effective date of coverage. This date should not be after the Date of Service. The date format is MMDDYYYY. This date is used for the internal purpose of the Billing office and Hospitals. This does not form part of the HCFA-1500 claim form.

Example:
Eff. Date: 7-1-66; 07/01/1976; 07 01 66 …

3. Subscribers Name: This field contains the Subscribers name of the insurance policy. If the patient is a dependant who is covered under someone else’s policy then the name of the person who pays the premium is entered in this field. If patient is the subscriber then we need to enter the patient name itself. The name is entered in the Last Name, First Name MI format.
The Primary insurance subscribers name is printed in the 4th field and the Secondary insurance subscribers name is printed in the 9th field of the CMS-1500 claim form.

Example:
Subscriber: John Q. Public; Public, John Q …

4. Relationship Code: This field contains the relationship of the subscriber to the patient. The code is usually 1 – Self, 2 – Spouse, 3 – Parent, 4 – others etc…
This field does not form part of the CMS-1500 claim form.

5. Policy ID: This field contains the Policy number given by the insurance company to the subscriber and the dependants of the policy. This does not have any standard format across the insurance company but each insurance company has a unique format such as for Medicare the policy number is given as SSN + Alpha or Alphanumeric. The policy ID should be entered as given in the scanned card copy or as mentioned on the Encounter form.
The Primary insurance ID is printed in the 11th field and the Secondary insurance ID is printed in the 9a field of the CMS-1500 claim form.

Example:
Policy ID: 123-54-5478A; 215543251W1; 215-47-6491 …

6. Group ID: This field contains the Group ID as given by the insurance company for the policy. Not all the insurance companies have the Group ID hence if not given then this field can be left blank.
The Group ID is printed along with the Policy ID on the CMS-1500 claim form.

7. Pre-Auth. / Pre-Cert. Number: Review of "need" for inpatient care or other care before admission. This refers to a decision made by the payer, Managed Care Organization, or insurance company prior to admission. The payer determines whether or not the payer will pay for the service. Most managed care plans require pre-cert. This is a method of controlling and monitoring utilization by evaluating the need for service prior to the service being rendered. The practice of reviewing claims for inpatient admission prior to the patient entering the hospital in order to assure that the admission is medically necessary. A method of monitoring and controlling utilization by evaluating the need for medical service prior to it being performed. The process of notification and approval of elective inpatient admission and identified outpatient services before the service is rendered. An administrative procedure whereby a health provider submits a treatment plan to a third party before treatment is initiated. The third party usually reviews the treatment plan, monitoring one or more of the following: patient's eligibility, covered service, amounts payable, application of appropriate deductibles, co-payment factors, and maximums. Under some programs, for instance, pre-determination by the third party is required when covered charges are expected to exceed a certain amount. This number should be attached with the respective claim; otherwise the claim will be rejected. There is no standard format for Auth and Pre-Cert. number across all the insurance companies. Each insurance company has its own unique format of Auth and Pre-Cert. numbers.
This field is printed in the 23rd field of the CMS-1500 claim form.

8. Referral Number: A Referral number is provided by a PCP (Primary Care Physician) when he refers a patient to a specialist. Without the Referral number a patient cannot get a specialist’s service if he has a HMO plan.
This number is printed on the CMS-1500 claim form or entered in the attached documents as per the Insurance company requirements.

9. Date of Injury/Accident: This field is used to enter the Date of Injury/Accident when the claim is filed to Work Comp/Auto Accident insurance. This date is useful for the insurance companies to verify if the coverage was active or not. This date is mentioned in the documents attached while filing the claim.

10. Claim Number: This field is used to enter the Claim number for a particular claim given by the Work Comp/Auto Accident insurance company. Failing to mention this number on the claim form will result in the rejection of the claim.
This is mentioned in the attached documents while submitting the claim.

PATIENT DEMOGRAPHICS – AN OVERVIEW - 2

6. Marital Status: This field contains the Marital Status of the patient. It is usually entered as ‘S’ for Single, ‘M’ for Married, ‘D’ for Divorced, ‘W’ for Widow/Widower, ‘X’ for Separated and ‘O’ for Others. It marital status is missing from patient encounter form, we need to enter ‘O’ in the marital status field.
This field is printed in the 8th field of the CMS-1500 claim form.

Example:
Marital Status: Single; Married; Divorced; Widow …

7. Address: Patient’s address is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Appt. #), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code. This field can not be left blank. Patient address is a important field to file a claim & send patient statement. Following are the general abbreviations found in patient encounter forms:

a) Apt. # - Apartment number
b) Ave. - Avenue number
c) Blvd. - Boulevard
d) Ste. - Suite/Street
e) Dr. - Drive

This field is printed in the 5th field of the CMS-1500 claim form.

Example:
Address: 1067 Orange Grove Blvd.
Apt. # 194
Los Angeles, CA 90001

8. Patient Phone Number: This field contains the contact number of the patient including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code, and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications.
This field is printed in the 5th field of the CMS-1500 claim form along with the address.

Example:
Phone Number: 626-843-2846; (626)357-5496 …

II. Patient Employer information

This segment in the face sheet contains employer information of the patient. The entry person needs to enter this information if available in face sheet. Employer information is a must for worker’s comp claims. Non-worker’s comp claims do not require employer name to process claims but it is advisable to update employer information during entry. Following information’s are found in this segment

1. Employer Code
2. Employer Name
3. Employer Address & Phone #
4. Designation/Occupation
5. Contact Person

1. Employer Code: This field is used in most of the Billing Software’s to reduce the time of PD entry. The Names and Addresses of the major Employers are stored in the Employer database with a unique code assigned to each employer. Hence it is enough to just enter the code and skip to the next block.

Example:
Employer Code: IBM; A0012; MS024 …

2. Employer Name: This field contains the name of the patients Employer. If the patient is a Student or Not Employed or Retired then it can be entered as Student or Not employed or Retired in this field.
This field is printed in the 11b field of the CMS-1500 claim form.

Example:
Employer: Verizon Wireless; Microsoft Corp.; SUN Microsystems …
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3. Employer Address: The address of the patients Employer is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code.
Example:
Address: PO Box 1954
Los Angeles, CA 90001-1954

4. Employer Phone Number (Ext No.): This field contains the contact number of the patients Employer including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications. Some software’s may also require you to enter the Extension number if given on the encounter form.

Example:
818-245-7849 [5478]; (818)-245-7849 …

III. Patient Guarantor Information

This segment in face sheet consists of guarantor or emergency contact information.

They are:

1. Guarantor Account #
2. Guarantor Name
3. Guarantor Address
4. Guarantor phone #
5. Guarantor/patient relationship
6. Guarantor employer & SSN

This block is mostly entered only in the case of the patient being a minor or if the patient is not responsible for the payment. This information is for the internal purpose of the Billing Office and the Hospitals for the purpose of Emergency Contact or follow-up of pending balances and hence does not form part of the CMS-1500 claim form.

1. Guarantor Account #: This field is used to enter the guarantor account #. If the guarantor is already stored in the database then the stored information can be pulled up using this number. This information is not part of the encounter form. The account number of the guarantor is pulled using search engine.

Example:
245818A; 6252315; 421154; …

2. Guarantor Name: This field is entered in the Last Name, First Name Middle Initial format. However in some software’s this field is split as Last Name First Name and Middle Initial fields. The guarantor name may also contain title (Junior, Senior, I, II, III …) and suffix (M.D. …) this information also needs to be entered along with the name. The title must be entered with the last name and the suffix should be entered with the first name or after the middle initial. The Name on the Encounter Form may not be given in above said format but still it should be entered as per the Billing Software specifications.

Example:
Joseph Warowes Sr.; Warowes, Virginia E M.D …

3. Relationship: This field contains the relationship of the Guarantor with the patient, such as Spouse, Parent, Others etc.

Example:
Relationship: Spouse; Parent; Grand Parent …

4. Address: The address of the Guarantor is split into 5 different fields. It is usually entered as Address1 (PO Box#/Door#/Apt.#), Address2 (Street/Ave. /Blvd. Name), City, State and ZIP code.

Example:
102 West 35th Street
Heathsville, GA 65418

5. Phone Number: This field contains the contact number of the Guarantor including the area code. It contains a total of 10 digits (111-222-3333), the first 3 digits are the area code and the next 7 digits are the phone number of the patient. If the area code is not specified the phone number can still be entered leaving the area code field blank or entering some dummy number as per the Billing Software specifications.

Example:
(517)373-1820; 517-374-5857 …

6. Guarantor Employer: This field contains the guarantor’s employer information. Basically the guarantor’s employer name, address, and contact details are entered here.

7. Emergency Contact: This field is used to enter the Emergency Contact details of the patients relative or next of kin. Contact information such as Name, Address Phone # and relation to the patient are entered here.

IV. Physician Information

This segment contains the following information.

1. Admitting physician code: The physician responsible for admission of a patient to a hospital or other inpatient health facility. Some facilities have all admitting decisions made by a single physician (typically a rotating responsibility), called an admitting physician. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details. This field is optional; if the Admitting physician info is not given it can be left blank.
This field does not form part of the HCFA-1500 claim form.

Example:
Adm. Phy.: Mileski MD, William

2. Attending or Rendering physician code: The physician rendering the major portion of care or having primary responsibility for the care of the patient's major condition or diagnosis. In other words the doctor or supplier who actually renders the service (also referred to as a "rendering physician"). All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details.
The Name of the rendering physician is printed in the 33rd field along with the Address and Phone #. The rendering physician’s Federal tax ID stored in the database is automatically printed in the 25th field of the CMS-1500 claim form.

Example:
Att. Phy.: Pendridge MD, Dayton

3. Referring Physician/Primary Care physician code: The physician who has sent the beneficiary to another physician or, in some cases to a supplier (e.g., physical therapist, occupational therapist) for consultation and/or treatment is called a referring Physician or Primary Care Physician (PCP). The name of the facility may be reflected in this area if the patient has not identified a unique physician, but has identified a facility. All the information’s related to a particular physician (Physician Name, UPIN, Federal Tax ID, License #, Facility Address & Phone #) are stored using a unique code in the provider database. Hence while selecting a physician codes the entry person should be very careful to select the correct code after cross checking all the relevant details.
The name of the referring physician is printed in the 17th field and the corresponding UPIN stored in the database is printed in the 17a field of the CMS-1500 claim form.

POS Plan

POS Plan ( POINT OF SERVICE PLAN )

POS plans are more flexible than HMOs, but they also require patient to select a PCP.

POS
advantages:
• Depending on patient insurance company's rules, he may choose to visit a doctor outside the network and still receive coverage — but the amount covered will be substantially less than if patient went to a physician within the network.
• These plans tend to offer more preventive care and well-being services, such as workshops on smoking cessation and discounts to health clubs.

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POS disadvantages:
• Individual must choose a PCP.
• While individual may choose to see a physician outside the network, if he did not receive permission from PCP, individual is likely to wind up submitting the bills himself and receiving only a nominal reimbursement — if any.

PATIENT DEMOGRAPHICS – AN OVERVIEW - 3

PATIENT CHARGES – AN OVERVIEW

• What are Patient Charges and what does it contain?

Patient charge is nothing but the fees claimed by the physician who rendered the services to the patient. Charges can be either based upon demographic evaluation or a flat fee rate as prescribed by the physician’s office. Each piece of information is important because correct and quality entry of such information will directly impact physician’s monthly revenue. This sheet is also called as face sheet of a charge or claim.

• How Charge Sheets originate and reach us?

Once patient /spouse completes Pd sheet, patient is then referred to physician in the appointed time. After preliminary investigation physician provides the services required by the patient. In the super-bill, kind of treatment is denoted by procedure code and diagnosis code denotes the nature of illness for which services were administered.
Super bills or charge sheets contain information like Date of Service, Kind of Service, Diagnosis Code, Attending Doctor, Modifier details. Super bills are usually completed by physician or their assistant. Sometimes Coding of diagnosis & procedures are done by coding specialists.
Once Charge sheets are completed, they are batched with PD at physician’s office and are forwarded to our office for charge entry. Mode of transfer of data may vary from client to client. But most preferred mode is thru FTP. Here patient demographics are scanned & captured as image file. These image files are placed in FTP site. These image scan files are retrieved at our office & charge entry begins.

• For our easy understanding now let us see each of the information found in patient charge sheet. Information found in patient charge sheet is 1. Attending Physician 2. Referring Physician 3. Admit Date 4. Date of Service 5. Type of Service 6. Place of Service 7. Prior Authorization Number 8. Modifiers 9. Procedure code 10. Diagnosis Code 11. # Of days/ units, 12. Location Details 13. Physician Name, Address, Provider id

1. Attending Physician: Attending physician is also referred as rendering physician. A physician who renders the service to patients is called attending or rendering physician. Each Rendering/Attending Physician of a particular facility is assigned a unique code with the Name of the Physician, Address of the Clinic/Facility, PIN (Provider Identification Number), License number, Federal TaxID#.

The Rendering Physician Name, Address, and PIN are printed in the 33rd field and if the Address of the Facility where the service was rendered differs from the Physicians location then that address is printed in the 32nd field and the corresponding Federal Tax ID of the Provider is printed in the 25th field of CMS-1500 form.

Medicaid

The Medicaid Program provides medical assistance for certain individuals and families with low incomes and resources. Medicaid eligibility is limited to individuals who fall into specific categories. Although the Federal government establishes general guidelines for the program, the Medicaid program requirements are actually established by each State

Medicaid eligibility is limited to individuals who fall into specified categories. The federal statute identifies over 25 different eligibility categories for which federal funds are available. These categories can be classified in to five broad coverage groups:
• Children;
• Pregnant Women;
• Adults in Families with Dependent children;
• individuals with disabilities;
• and individuals 65 or over

Long-Term Care Insurance

Long-term care insuranceis designed to cover the costs of nursing home care, which can be several thousand dollars each month. Long-term care is usually not covered by health insurance except in a very limited way. Medicare covers very few long-term care expenses. There are many plans and they vary in costs and services covered, each with its own limits