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    Welcome to the ClaimCare Medical Billing Blog. We strive to provide content that improves the overall quality of medical billing efforts across the US. If you have any specific topics that you would like to see addressed in this medical billing blog please post the topic in the Medical Billing Questions & Answers Forum. If you have an article that you would like considered for publication in the medical billing blog then please email your article to resources@claimcare.net.


    Untangling Knots in Medical Billing Process

    Posted by Carl Mays on Fri, Nov 15, 2019 @ 10:00 AM

    Untangling the Knots of the Medical Billing Process

    Medical billing is the process of submitting and following up on claims with health insurance companies in order to receive payment for services rendered by a healthcare provider.





    This task involves several individuals, including:

    • Office administrators
    • Receptionists
    • Medical billers
    • Medical coders

    It is important for any medical practice to know how the medical billing process works in order to avoid facing several problems related to the process.

    Six Steps Involved in the Medical Billing Process

    Effectively (doing the right thing) and efficiently (doing the thing right) while handling the following steps in the medical billing process is crucial for the success of your revenue cycle.

    Step 1: Patient Check-In

    The medical billing process starts the moment the patient requests an appointment with the physician. From here, the receptionist or front desk officer gathers patient information, which includes the following:

    • Name
    • Address
    • Birthdate
    • Contact number
    • Reason for visit
    • Insurance provider
    • Policy number

    It is important to accurately encode this information into the EHR system. Any wrong data encoded may be a cause for a denied or rejected claim in the future.

    Step 2: Confirming Insurance Eligibility of the Patient

    After recording or updating the initial information, the patient’s insurance coverage should be verified by the office administrator. This includes identifying the list of services covered in the patient’s current insurance policy. The administrator should also be aware of the different billing procedures required by a provider, such as the need for pre-authorization prior to billing.

    Once these things have been clarified, the office administrator needs to inform the patient if he or she needs to pay out of pocket for certain services.

    Step 3: Handling the Patient Check-Out

    All services rendered for the patient must be recorded and placed into the patient’s medical record. This means translating all the diagnoses and medical procedures into medical codes. This is where medical coders enter the picture.

    Medical coders determine the diagnoses of the treatments that have been administered to the patient. This is then translated using the ICD or CPT code and encoded into the patient’s ledger.

    Here, the patient’s bills, including previous balances (if any) and new charges, are input in relation to any payments the patient or patient’s provider may have paid, all of which are printed and given to the patient in the form of a receipt.

    Step 4: Accurately Transmitting the Medical Claim

    Now that the diagnoses and treatment services have been properly coded, it is time for the billers to transmit the medical claim to the insurance provider. However, before this is transmitted, it needs to be reviewed internally. This means adhering to written standards and procedures designed by your organization to reduce erroneous claims and fraudulent activity.

    This ensures all data has been accurately entered electronically into provider’s system through a clearinghouse or directly to the provider, such as Medicaid.

    Step 5: Receiving the Payment

    Once the medical claim is received by the insurer, it is reviewed and evaluated. The insurer determines if the entire or just a portion of the bill should be paid, or if it should be denied. All of this depends on the policy and the contract the patient signed with the insurer.

    Step 6: Billing the Patient

    There are instances wherein the patient needs to pay for the remaining bill not covered by the provider. This is the reason why some insurers and healthcare providers implement a co-payment policy.

    If the patient fails to pay the bill accordingly, it is the responsibility of the healthcare provider to followup with the patient through a collection process. Thus, it is important to explain to the patient upfront about the entire medical billing process.

    Learn more medical billing tips. Subscribe and follow our blog today.


    About ClaimCare

    ClaimCare provides a complete solution for all your medical billing concerns. This includes claim submission and follow-up processing, practice analytics and recommendations, instant payment program, automated insurance verification, and patient checkout tool. Learn more about the services we deliver. Complete our online form to schedule an appointment with us.



    Tags: medical billing, medical billing services, medical billing process

    Why Your Practice May Need a Medical Billing Company

    Posted by Carl Mays on Thu, Nov 07, 2019 @ 02:00 PM

    Why You Need a Medical Billing Company for Your Upcoming Private Practice

    According to a 2019 survey by the Kaiser Family Foundation (KFF), there are 478,463 Primary Care Physicians in the USA – and according to a 2019 survey by Statista, there are currently 525,439 Specialty Physicians. (Click on links to see categories and states.)

    From these lists of physicians, some are succeeding well, others are struggling to break even, and still others are closing their offices. Meanwhile, incoming physicians are aspiring to establish their own practices.

    One of the reasons why some practices have failed or are currently struggling to stay open is the lack of strategic planning. Such practices have failed to realize that establishing a private practice is not an easy endeavor and have not answered the questions that all practices face:

    • What are the different measures you need to consider to ensure your practice will survive for several years prior to becoming soundly established?
    • Can you handle the start-up challenges on your own, or do you need the help of another company?
    • Does help from another company include obtaining the services of a professional medical billing company?

    A current source that deals with the challenges of setting up your own medical practice is found in the online magazine, Business News Daily. The January 10, 2019 article is titled:

    How to Open a Private Medical Practice, Step by Step

    This article emphasizes that at the very least, anyone who intends to set up a medical practice should be prepared for the following:

    • Equipment costs of no less than $100,000
    • A line of credit with a minimum of $100,000
    • Enough operating capital for several months
    • Obtaining a medical practice tax ID
    • Obtaining liability and malpractice insurance
    • Obtaining insurance/payer credentialing
    • Deciding on how to handle medical billing

    Along with the basics of capitalization and the other fundamentals of opening a new medical practice, come important additional needs:

    Choosing your staff

    ClaimCare points to an online blog titled Manage My Practice, which covers descriptions of a dozen or more staff members, but begins with the absolute minimum number of staff required:

    1. Front Desk Officer
    2. Clinical Assistant

    This minimum staff means that the front desk officer should be knowledgeable in many areas, including filing medical billing claims and processing your medical credentials. But what happens if the front desk officer can’t come to work? Who will handle her or his duties for the day or possibly longer, including the medical billing?

    Also, rather than one clinical assistant, it is best to have two who can interchange schedules in case one of them becomes ill or is unavailable for work for some other reason.

    The Manage My Practice Blog also responds to the following questions regarding staff:

    1. Why do some offices need more staff and some need less?
    2. What should you do if you can’t figure out if it’s taking too many people to do the work?

    Returning to the Business News Daily article, other needs covered include:

    Purchasing and installing your equipment

    Eight pieces of equipment, with accompanying software, are detailed in this article and, importantly, the first three mentioned are extremely vital to your revenue cycle:

    1. Electronic Health Record System
    2. Practice Management System
    3. Medical Billing System

    Without someone to utilize these software systems effectively (doing the right thing) and efficiently (doing the thing right), you will experience a waste of time and a financial loss.


    How a medical billing company helps your practice

    A medical billing company has a pool of highly skilled medical billers and coders. These professionals have been trained to use various software systems including the above-mentioned. Thus, by working with a third party medical billing provider you are eliminating the burden of finding or training someone to utilize these systems to reach your optimal advantage. As a result, you can better focus on your core offerings and concentrate on further improving your medical services. This also gives you additional time to think of ways to further expand your patient outreach.


    About ClaimCare

    ClaimCare understands the needs of new medical practices. Thus, it provides services that aid you with credentialing and contracting. As needed, it also helps in training your front desk staff with all of these processes.

    In all medical billing areas, ClaimCare:

    · provides the top service level guarantee in the industry

    · offers best-of-breed technology,

    · is based 100% in the U.S.A.

    · has an air-tight medical billing process

    · provides actionable reporting and broad experience

    · can work on its clients' medical billing systems.

    Healthcare Tech Outlook named ClaimCare as one of the nation’s “Top 10 Medical Billing Companies” in 2019. This honor follows previous such honors, including being ranked in the “Top 5” by the online magazine, Money & Business.

    ClaimCare has a proven track record of increasing client collections by 10 to 20 percent.

    For more information, contact ClaimCare Medical Billing Services at sales@claimcare.net, or phone (855) 376-7631, or visit the ClaimCare Medical Billing Company website.

    Tags: medical billing services, medical billing resources

    New Medicare Card: MBI Transition Ends December 31, 2019

    Posted by Carl Mays on Thu, Oct 24, 2019 @ 10:30 AM


    On October 17, 2019, the Centers for Medicare & Medicaid Services (CMS) sent this reminder:

    New Medicare Card: MBI Transition Ends in Less Than 10 Weeks.

    ClaimCare posted a blog back on September 17, 2018, titled Top Three Impacts of Medicare ID Card Changes on Medical Billing Services. You can review the 2018 post and see that it covers several important points and then goes into some detail regarding:

    1. Eligibility Verification of the New Medicare ID Card

    2. Coordination of Benefits with the New Medicare ID Card

    3. Submission of Medical Claims Using the MBI

    Since the transition period that began April 1, 2018, CMS has posted quite a few notices dealing with clarifications and revisions to the initial announcement.

    Previous CMS announcements in 2019 include the following:

    September 26: New Medicare Card: More Questions about Using the MBI?

    September 19: New Medicare Card: Why Use the MBI?

    August 08: New Medicare Card: Will Your Claims Reject?

    July 25: New Medicare Card: Questions about Using the MBI?

    June 20: New Medicare Card: 75% of Claims Submitted with MBI

    March 28: New Medicare Card and MBI Adoption: How Do You Compare?

    March 06: MBI Look-Up Tool Can Be Used With Medicare Advantage Plans (PDF)

    January 10: New Medicare Card: Transition Period Ends December 31

    If you review these announcements, you will see that the majority of practices and facilities have already made the necessary changes, with many tweaking things along the way. Some, after having claims rejected, are learning more about the process. Others have assisted their patients in making sure they have the new cards and have educated them on why the change in cards became necessary.

    If you still need help with the transition in any way during these final weeks prior to the mandated deadline of January 1, 2020, ClaimCare can provide that help.

    In all medical billing areas, ClaimCare:

    · provides the top service level guarantee in the industry

    · offers best-of-breed technology,

    · is based 100% in the U.S.A.

    · has an air-tight medical billing process

    · provides actionable reporting and broad experience

    · can work on its clients' medical billing systems.

    Healthcare Tech Outlook named ClaimCare as one of the nation’s “Top 10 Medical Billing Companies” in 2019. This honor follows previous such honors, including being ranked in the “Top 5” by the online magazine, Money & Business. ClaimCare has a proven track record of increasing client collections by 10 to 20 percent.

    For more information contact ClaimCare Medical Billing Services by email at sales@claimcare.net, by phone at (855) 376-7631 or visit the ClaimCare Medical Billing Company website.

    Tags: medical billing services, medical billing resources

    3 Data Analytics that Should Always Be Included in Your Medical Billing Report

    Posted by Carl Mays on Wed, Sep 11, 2019 @ 03:00 PM

    3 Data Analytics that Should Always Be Included in Your Medical Billing ReportMedical billing reports are important in evaluating the efficiency of your practice. Thus, reports should show the performance of your organization in full details. This will greatly help in improving your revenue cycle.




    Some of the questions reports should be able to answer include:

    • Referring physician profitability
    • Front desk employee effectiveness
    • Payer contractual compliance
    • Provider productivity
    • Coding profiles

    How is this possible? Read on to know the different data analytics that should be present in your medical billing report.

    1. Accounts Receivable Aging Report

    This report contains any accounts receivable (A/R) that remain to be paid by the insurance companies. It also reveals how long A/R has been unpaid and the average time a claim needs before it is paid by the insurance provider.

    As an example, for CIGNA HealthCard holders, Cigna says they do their best to process medical claims within 5 days after filing.

    Five days may not be possible, but medical claims should be paid in less than 45 days. Thus, any claim that extends beyond 45 days to be paid should immediately be monitored. If this reaches 90 days, then it is a red sign that you should urgently take action with it.

    As a friendly note, you should also consider the type of claim you are requesting. Generally, the following claims take longer to be processed:

    • Workers compensation
    • Car accident claims
    • Out-of-state claims

    Thus, it is best to be mindful of any healthcare services provided under this category.

    2. The Key Performance Indicators (KPI) Report

    Just like any business, your practice should know the most profitable procedures in your organization. Thus, your key performance indicator report should be able to track the following:

    • Frequency a procedure is performed
    • Sum charges and collection
    • Total adjustments
    • Outstanding A/R

    This should be neatly presented in a document so you can easily compare results on a per-date basis. Any sudden surge or leap in weeks or days should be carefully noted so you can monitor these dates more meticulously.

    3. The Insurance Analysis Report

    This lists the top payers and insurance companies contributing to your practice, based on the collection per Total Relative Value Unit (RVU).

    But what exactly is an RVU?

    This represents the following components:

    • Physician work expenses: 52%
    • Practice expenses (staff, facilities, overhead): 44%
    • Malpractice expenses: 4%

    It is further influenced by the area of the country in which the service is provided. This, together with the above components, comprises the total RVU of a particular service.

    Why is this important for your practice?

    Knowing the collection per total RVU of your procedures gives you the leverage to negotiate for better pricing with various insurance companies.

    How do you know if you are making a smart negotiation?

    Ideally, the collection per Total Relative Value Unit should be higher than the current Medicare Conversion Factor, which is $36.04. If this is lower, then you are not collecting the right amount for your services.

    Check who among your payers are paying less and start talking to them about it. If they will not settle with an agreement, then it may be better to drop them and add another carrier that pays better. However, be extra careful before dropping one of your carriers because it may have an impact on your practice.

    For better results, seek the advice of experts in the field of medical billing and coding to help you make an assessment of your current medical billing reports.

    Do you wish to know more about medical billing and coding practices? Subscribe to our blog for more helpful insights or complete our online form so we can schedule an appointment with you. You may also contact us at (855) 376-7631.

    About ClaimCare

    ClaimCare delivers medical billing and coding reports with detailed information for you to fully understand the state of your practice. This helps your organization to create action plans that can help improve your performance. It also comes with an easy-to-use dashboard reporting system, which easily presents critical information in a comprehensive manner.


    Tags: medical billing, medical billing resources

    Rejected Medical Claims vs Denied Medical Claims: What's the Difference?

    Posted by Carl Mays on Tue, Sep 10, 2019 @ 03:20 PM

    Rejected Medical Claims vs Denied Medical Claims_ Whats the DifferenceLooking back, to look ahead: With ICD-11 on the horizon for 2022, Centers for Medicare & Medicaid Services (CMS) reported in 2015 that claims were processed with fewer rejected and denied claims after the transition from ICD-9 to ICD-10. Rejections and denials are projected to decrease even more when ICD-11 takes effect.

    Meanwhile, while dealing with ICD-10, many providers are confused on how to differentiate “rejected” medical claims from “denied” medical claims. This article discusses how you can distinguish the two from one another and steps on how to avoid both.

    What are rejected medical claims?

    These medical claims are considered unpayable and are sent back by the payer due to:

    • Incorrect information
    • Failure to meet specific data requirements
    • Non-adherence to the required formatting

    Due to these reasons, rejected medical claims are not even entered into the computer systems of payers. Thus, they cannot be processed.

    Once the error has been fixed, rejected claims can be submitted for approval. Thus, it is important for your medical biller to properly code and complete the information required by the payer.

    How are denied medical claims different from rejected medical claims?

    Unlike rejected medical claims, denied claims have been received and processed by the payer, but considered unpayable. Although these claims can be resubmitted, it should be done with a reconsideration request or appropriate appeal. Otherwise, it will just be denied once again costing your practice or facility more time and money.

    What causes a medical claim to be denied?

    Several factors can result in a denied medical claim. This includes:

    • Incorrect patient identifier information
    • Termination of medical insurance coverage
    • Requirement of prior authorization or precertification
    • Excluded or non-covered services
    • Requires supplementary medical records
    • Auto or work-related incident
    • Invalid CPT or HCPCS codes
    • Lapse of the filing date
    • Lack of referral on file

    Thus, make sure your medical billers and coders are knowledgeable regarding the latest medical coding updates and are skilled in properly preparing your medical claims. Otherwise, you’ll have instances of medical claims being denied and rejected by the payers.

    How can you improve your practice’s claim rejections and denial rates?

    There are several ways to improve your claim rejections and denial rates:

    1. Analyze and track your payer denial and rejection trends

    Review the most common types of mistakes and coding errors committed by your medical billing team. Create routine chart audits for documentation and data quality. Based on this information, create a course of action that will minimize, if not eliminate, these errors.

    2. Educating your medical billing and coding staff

    Invest in training your staff. Provide training on how to handle claim denials and rejections appropriately.

    Otherwise, consider outsourcing your medical billing to an “Experienced” and ”Knowledgeable” medical billing company. In this manner, you are guaranteed that the team handling your medical billing is well equipped, skilled, and knowledgeable in completing these tasks.

    3. Discuss your concerns with payers

    Schedule an appointment with your payers. Discuss, revise, or eliminate contract requirements resulting in denied claims, which eventually get overturned after an appeal. This helps to clarify the requirements in order to avoid future medical claim rejections.

    Are you having problems with your medical claim submissions? Do you need help processing these claims? Subscribe to our blog for more tips and updates.

    About ClaimCare

    ClaimCare has more than 25 years of experience in providing medical billing and coding services to various practices. Throughout these years, they have helped numerous organizations increase their revenue cycle by eliminating medical claim rejections and denials. Complete our online form or call us toll-free at (855) 376-763 to learn more about the services we deliver.

    Tags: medical billing, medical billing services, medical billing resources, clean claims

    4 Steps to Painless Physician Credentialing

    Posted by Carl Mays on Thu, Sep 05, 2019 @ 10:00 AM

    4 Steps to a Painless Physician CredentialingThe famous Chinese philosopher Confucius once said, "A man who does not plan long ahead will find trouble at his door." This is true, especially with healthcare providers in the U.S. and their physician credentialing process.

    In a study conducted and published by the Beckers Hospital Review, it has been revealed that a one month delay in physician credentialing can result in a $30,000 loss in revenue. This amount further increases for higher billing specialties such as cardiothoracic surgery and orthopedics. Thus, it is important for healthcare providers to plan properly for their physician credentialing procedure to ensure their cash flow will run smoothly in 2019.

    These steps will help you organize your physician credentialing process:

    Step 1: Start Early

    Physicians Practice, an online publication, said that most physician credentialing can be done within 50 to 90 days, but it is best to give your practice a 120-day leeway. This is because the internal timeline of the payer who processes the application varies, differing from one payer to another.

    Given this timeframe, it is best to start your physician credentialing process earlier, preferably prior to hiring.

    Step 2: Pay Attention to Detail

    Perform the necessary due diligence when submitting your application.

    Many physician credentialing delays are caused by incomplete and incorrect information. This is a simple mistake that can cost you a huge sum of money. Thus, it is important for your team handling the physician credentialing process to pay close attention to all of the required information.

    Double check to see if all of the entries have been properly filled out. In doing so, you'll have a more efficient physician credentialing process, which means completing it within 50 to 90 days. Plus, you avoid going through the process of re-applying.

    Step 3: Remain Updated with the Coalition for Affordable Quality Healthcare (CAQH)

    In December 2018, CAQH announced new functionality for Verifide ™, This automated solution verifies the accuracy and completeness of credentialing information submitted by healthcare providers to health plans.

    This will now become the primary source verification (PSV) as it offers real-time visibility into your credentialing application status. As a result, your practice will have an easier time knowing the reason behind your physician credentialing rejection or denial.

    Thus, you should always be in the loop with the latest updates provided by CAQH.

    Step 4: Be Knowledgeable with State Regulations

    State regulations vary from one another. For some states, a physician credentialed by Provider A in another state may be streamlined in their states; others may allow a physician to avoid the full credentialing process again when moving from one practice to another within the same state.

    Just take a look at Texas. A credential verification organization has been launched through the collaboration of Texas Medical Association and 19 Medicaid health insurance plans. The organization’s goal is to reduce paperwork for Texas physicians.

    Amanda Hudgens, director of special projects for The Texas Credentialing Alliance (TAHP), stated:

    "We want to simplify the credentialing process for physicians here in Texas and we're focusing on Medicaid providers because we understand they have a lot of paperwork burdens and administrative requirements to become a Medicaid provider."

    Thus, it is important for the one handling your physician credentialing to know all about these varying state regulations.


    The physician credentialing process remains a tedious process if you do not have all the information you need up front. Following the above recommendations will help speed up this process while eliminating inefficiencies.

    Subscribe to our blog for more tips related to medical billing or call us toll-free at (855) 376-7631 for your queries and concerns.

    About ClaimCare

    ClaimCare helps new medical practices and existing organizations with their physician credentialing process. They even assist in training your front desk office staff for a more efficient medical billing process. Learn more.

    Tags: medical billing resources, credentialing, medical credentialing

    5 Factors to Consider When Choosing a Medical Billing Company

    Posted by Carl Mays on Wed, Sep 04, 2019 @ 10:00 AM

    5 Factors to Consider When Choosing a Medical Billing Company_On December 15, 2015, Jason Adam Townsend, owner of a medical billing company, was indicted on healthcare fraud and aggravated identity theft charges by the Charlotte Grand Jury.

    Don't fall victim to these fraudulent medical billing companies. Know how you can select a reliable medical billing company for your medical billing needs.

    When looking for a medical billing company, it is important to consider the following factors:

    1. Service Level of the Medical Billing Provider

    What are the services provided by your medical billing company? Does this include:

    • Pursuing denied claims
    • Billing follow-up
    • Complying with industry regulations
    • Reporting and analysis

    Ensure you discuss these matters with the company before signing up for any of their packages. Doing so will confirm if they are the right service provider for you.

    2. Years of Experience in the Industry

    How long has the medical billing service provider been in the industry? On what medical specialties do they focus?

    These are important questions to consider when choosing a medical billing service provider because it shows if they are knowledgeable in the following areas:

    • Current medical coding system and medical terminology
    • Insurance claims and billing, which includes the appeals and denial process, as well as fraud and abuse detection
    • Information and web technology
    • Reimbursement practices

    3. Knowledge with the Use of Technology

    One of the aims of medical billing is to accomplish more tasks with less time. This is done through the use of sophisticated billing software. But, it does not mean having to work on an entirely new system altogether.

    While most medical billing companies have their own billing system, very few have the capacity to work with the existing system used by an organization. Thus, you are forced to migrate your data into their own. However, this makes the transition process longer and more complicated.

    Rather than migrate your data into a new one, you may prefer a medical billing company  like ClaimCare that can work in your current billing system. In this manner, you don't have to worry about your data being transferred into a new system.

    Thus, it is important to ask them the following questions:

    • Are they willing to work in your current system?
    • How knowledgeable are they with other billing systems?
    • How long will it take to integrate with your billing system?

    4. Security and Compliance

    According to the National Healthcare Anti-Fraud Association NHAA, approximately tens of billions of dollars are lost to health care fraud. This makes it one of the most challenging problems among medical providers.

    Avoid being a victim. Carefully select your medical billing company by inquiring if they perform one or more of the following safety precautions:

    • Annual background checks on their employees
    • Monthly annual checks with the OIG for excluded employees
    • Anonymous methods on how to report employee violations
    • Health Insurance Portability and Accountability Act (HIPAA) training
    • Dedicated compliance officer to ensure your data remains protected

    This will help you assess how much these medical billing companies value the confidentiality of all your records.

    5. Medical Billing Service Efficiency

    Check the performance of the medical billing companies you’re considering. Identify how much of the denied claims and fee collection they are able to deliver by asking for the following data:

    • How many of their current clients match your specialization?
    • How many claims do they process each year?

    It is also helpful to know the following information:

    • Percentage of reduced payment delays
    • Increased revenues they deliver to their existing clients
    • Average number of days in A/R by specialty percentage

    Utilize all of this information when choosing a medical billing company. Remain updated with the current medical billing trends and issues. Subscribe to our blog or call us at (855) 376-7631 for any of your medical billing concerns.

    About Claimcare

    ClaimCare has more than 25 years of experience in medical billing. It has a proven track record of increased customer collection reaching all the way up to 25% (the average increase is approximately 5%) and days in AR under 40 for your collectibles.

    Tags: medical billing, medical billing companies, medical billing services

    5 Reasons Your Medical Claims Are Being Denied

    Posted by Carl Mays on Tue, Sep 03, 2019 @ 10:00 AM

    5 Reasons Your Medical Claims Are Being DeniedSome of the crucial elements in the medical claims process happen during the medical coding and medical billing procedures.

    This article discusses how these two procedures are essential in filing medical claims and why your medical claims are being denied.

    How Medical Coding and Medical Billing Influence Medical Claims Approval

    Medical coding is the process of accurately encoding written documents (e.g., a medical prescription or diagnosis) made by medical experts into a numeric or alphanumeric one. On the other hand, medical billing is the process of assigning a corresponding bill for the insurance or healthcare provider.

    Any incorrect or incomplete coding and billing can result in a denied claim for the following reasons:

    1. The coded information lacks detail or is not clearly rendered by the coder

    There are codes for specific medical terms. It is important for the coder not to overlook even the tiniest bit of information contained therein. The code must be complete. If the coder neglects to input one number or includes an irrelevant one, the code is invalid.

    For example, k35 is acute appendicitis while k35.80 is an unspecified acute appendicitis. Failing to indicate the right type of appendicitis of the patient may be the cause for a denial. Thus, it is important that medical coders and billers be very knowledgeable about these codes.

    2. Mistakes due to outdated coding

    The coder must have an up-to-date book of codes. Documents coded using an outdated set of codes will only lead to an inaccurate output. The coder must be well informed regarding any changes in the coding system.

    3. The claim forwarded to the insurance company is missing relevant information

    Insurance companies are very meticulous. They review all the information required in the claim forms. Any missing information such as date of diagnosis, date of the accident, and any other relevant dates may be the reason for a claim denial. Thus, you should carefully review and ensure all the required information is properly incorporated in the claim forms.

    4. Delayed filing of the claim

    Submission of claims must be made within twelve months from the start date for Medicare. The start date can either be the date the medical service was performed or the date written on the “from” part of the claim form. The claimant may not be granted reimbursement if the filing is not made in a timely manner.

    5. The patient’s personal information is incorrect

    Your medical claims may also be denied if the personal information input into the system is erroneous. Name, age, sex, and other personal details of the patient must be correct.

    Other relevant information such as the insurance company where the reimbursement is requested from and the policy number should also be valid. If the patient is not the insured himself/herself, be sure to state the relationship between the insured and the patient for the claim to be considered. Furthermore, the procedure performed on the patient must correspond correctly to the coded documentation prepared by the coder.

    Are you interested in learning more medical billing tips? Subscribe to our blog to remain posted. You may contact us online for any of your medical billing problems and concerns.

    About ClaimCare

    ClaimCare has years of industry experience in delivering high quality and affordable medical billing services in the U.S. We assist in collecting the maximum revenue for your practice while helping alleviate the medical billing costs and hassle for your organization.

    Tags: medical billing, medical billing services, Medical Reimbursement

    How Much Is In-house Medical Billing Really Costing You?

    Posted by Carl Mays on Wed, Aug 21, 2019 @ 02:03 PM

    How Much Is In-house Medical Billing Really Costing You_Is your in-house medical billing costing more than you can handle? How is this compromising your organization's efficiency?

    Learn how much you are actually spending on your in-house medical billing and how outsourcing it to a third party provider may be a more efficient and better cost-saving solution for you.

    Read on to know the details shared by The Physician's News Digest about medical billing costs in the US.

    The Cost of In-house vs an Outsourced Medical Billing

    Many practices believe that outsourcing their medical billing is more expensive. However, the analysis created by the Physicians News Digest shows it otherwise.

    And, the information supplied by The Physician's News Digest is based on an “average” medical billing company. ‘The Medical Billing Buying Guide’ gives ClaimCare, with our 100% USA-based staff, an A+ rating.

    Hypothetical Facts of the Practice Involved in the Physicians News Digest Analysis

    The following information was considered when creating the analysis of in-house medical billing costs:

    • 3 primary care physicians
    • 2 medical billing specialists
    • 80 insurance claims filed a day (̴20,000 per year)
    • $125 is the average billed amount per claim

    Employee Costs

    A practice with the above-mentioned activity needs two medical billing staff with an average of $40k salary to perform these processes. Thus, the practice is spending approximately $101,000 on them, including their taxes and benefits.

    With outsourced medical billing, there’s no need to think about the medical billing staff related expenditure. However, you would need to consider about five hours of time each week for managing tasks associated with billing at a rate of $15 per hour, which is equivalent to around $4,000 in administrative costs annually.

    Technology Costs

    This includes the following costs:

    • Electronic Health Record (EHR) system
    • Practice Management (PM) software
    • Hardware ($500)
    • Maintenance

    On average, the cost per doctor for the practice management software alone may reach approximately $200 per month. Thus, if the organization has three primary care doctors, it would mean an annual cost of approximately $7000. This doesn't include the upfront costs associated with software purchase and installation. Along with the computer hardware costs of $500, the annual total cost would be around $7500.

    With outsourced medical billing, you may only need to spend for a printer or the workstation that is required to communicate with the medical billing service provider.

    Training Costs

    Keeping your medical billing team updated with the latest coding and billing changes is a challenging task. On average, practices spend $2,000 on training alone. However, with a medical billing third-party provider, there’s no need to worry about this. It is their responsibility to keep all of their medical billing specialists knowledgeable with the latest coding changes. This ensures you always have accurate coding for all your billing services.

    Direct Claim Processing Costs

    The clearing house fees a provider needs to pay for submitting 20,000 claims is at $300 per month ($100 per physician) or $3,600 in a year. When outsourced, the fee is normally based on the percentage of the amount collected, which is normally at 7%.

    This is higher compared to the clearing house fees doctors have to pay. However, given the percentage of billing collected through a medical billing provider, this amount will immediately outweigh its costs.

    Billing Percentage Collected In-House vs Outsourced

    Amidst the higher direct claim processing costs of third-party medical billers, it delivers an increased 10% billing collection to your practice compared to an in-house medical billing team.

    Does this mean it is the right choice for your organization?

    There are many factors for you to consider such as:

    • Billing efficiency of your practice
    • Staff turnover and their technical skills
    • Years of experience in the industry

    If you are a new provider and experiencing high staff turnover with poor technical skills, then it’s better to choose a third-party provider to help you with your medical billing.

    Need help deciding? Call us at (855) 376-7631 or subscribe to our blog to learn more.

    About ClaimCare

    ClaimCare has over 80 years of medical billing experience. We serve virtually all specialties and help improve their billing collection. Learn more about our services. Most of our clients have experienced a 15 to 25% increase in collections and have days in AR under 40. Read more about us as reported by ‘Healthcare Tech Outlook.

    Tags: medical billing, medical billing services

    4 Common Pitfalls and Issues of Medical Credentialing

    Posted by Carl Mays on Mon, Aug 19, 2019 @ 02:00 PM

    4 Common Pitfalls and Issues of Medical CredentialingBeckers Hospital Review has revealed that just a month in delay on an average primary care physician's medical credentialing can cost your practice $30,000. This could even be higher for specialists who handle orthopedics and cardiothoracic surgery.

    Avoid this loss from happening to your organization. Learn the common issues associated with medical credentialing and how to solve them.

    1. Lack of Organization and Bad Workflow

    An efficient workflow will help you avoid medical credentialing problems and delays. Create a workflow to avoid lost money in handling appeals and reimbursements.

    Hire an office coordinator who will be:

    • In charge of your physician’s documentation process
    • Send reminder texts and emails for documents that are not yet submitted
    • Neatly compile these credentialing documents for easy retrieval

    This will help lessen human error in your workflow. Thus, avoiding the need for a re-credentialing process, which will only lead to a longer medical credentialing process.

    2. Lack of Timing and Physician Start Dates

    It’s good to be optimistic, but with medical credentialing it is best not to put things at a minimum, especially with estimating the time needed for the approval of your physician credentialing request.

    Gather all the needed credentialing paperwork on the day the employment offer is given. As needed, extend the start date of your new physician to a maximum to ensure you have properly reviewed and verified all of his or her credentials before joining your organization.

    3. Private Background Checks and Maintaining Updated Contact Information

    Medical credentialing is never easy. Payers will certainly use anything that can deny the payment claim. Therefore, it is important for your organization to diligently perform a private background check on your physician.

    Verify the validity of all the forwarded documents including:

    • License
    • Training
    • Employment history

    Most importantly, ensure the submitted contact information is up to date. The medical credentialing process may take a while, approximately 6 weeks to 3 months. Thus, it is important to know how you can contact them if any additional documents are needed by the payer.

    4. Adhering to All the Needed State Requirements

    Be reminded that states vary with their needed medical credentialing requirements. Additional credentialing requirements may still be necessary even if the physician has successfully been credentialed in another state. Therefore, it is better to check on reciprocity agreements with the payer organization and the state before agreeing to immediately accept the physician into your organization.

    Improve your organization's cash flow while providing quality healthcare to your patients. Do not let obscure state laws cause your office to lose productivity. Understand the laws of your state to make your medical credentialing process faster and easier.

    Do you have more questions about medical credentialing? Subscribe to our medical billing blog or complete our online form for any of your queries and concerns.

    About ClaimCare

    ClaimCare is one of the largest medical billing and medical credentialing providers in the United States. Its entire medical credentialing staff are thoroughly screened, well trained, and provided with the best tools and proper incentives to ensure you are given the best services. For more information about the services we deliver, phone (855) 376-7631.

    Tags: credentialing, medical credentialing

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