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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.


    Medicare Payment for COVID-19 Vaccine Increases!

    Posted by Carl Mays, ClaimCare President/CEO on Tue, Mar 16, 2021 @ 03:31 PM

    For COVID-19 vaccines administered on or after March 15, 2021, the national average payment rate for physicians, hospitals, pharmacies and other immunizers will be $40 per dose.


    This represents an increase from approximately $28 to $40 for the administration of single-dose vaccines, and an increase from approximately $45 to $80 for the administration of COVID-19 vaccines requiring two doses.

    The exact payment rate for administration of each dose of a COVID-19 vaccine will depend on the type of entity that furnishes the service and will be geographically adjusted based on where the service is furnished.

    This new and higher payment rate will support important actions taken by providers that are designed to increase the number of vaccines they can furnish each day, including establishing new or growing existing vaccination sites, conducting patient outreach and education, and hiring additional staff.

    At a time when vaccine supply is growing, Centers for Medicare & Medicaid Services (CMS) is supporting provider efforts to expand capacity and ensure that all Americans can be vaccinated against COVID-19 as soon as possible.

    CMS is updating the set of toolkits for providers, states, and insurers to help the health care system swiftly administer the vaccine with these new Medicare payment rates. These resources are designed to increase the number of providers that can administer the vaccine, ensure adequate payment for administering the vaccine to Medicare beneficiaries, and make it clear that no beneficiary, whether covered by private insurance, Medicare or Medicaid, should pay cost-sharing for the administration of the COVID-19 vaccine.

    Coverage of COVID-19 Vaccines

    As a condition of receiving free COVID-19 vaccines from the federal government, vaccine providers are prohibited from charging patients any amount for administration of the vaccine. To ensure broad and consistent coverage across programs and payers, the toolkits have specific information for several programs, including:

    Medicare: Beneficiaries with Medicare pay nothing for COVID-19 vaccines and there is no applicable copayment, coinsurance or deductible. 

    Medicare Advantage (MA): For calendar years 2020 and 2021, Medicare will pay providers directly for the COVID-19 vaccine (if they do not receive it for free) and its administration for beneficiaries enrolled in MA plans. MA plans are not responsible for paying providers to administer the vaccine to MA enrollees during this time. Like beneficiaries in Original Medicare, Medicare Advantage enrollees also pay no cost-sharing for COVID-19 vaccines.

    Medicaid: State Medicaid and CHIP agencies must provide vaccine administration with no cost sharing for nearly all beneficiaries during the public health emergency (PHE) and at least one year after it ends. Through the American Rescue Plan Act signed by President Biden on March 11, 2021, the COVID-19 vaccine administration will be fully federally funded. The law also provides an expansion of individuals eligible for vaccine administration coverage. There will be more information provided in upcoming updates to the Medicaid toolkit at Toolkit.   

    Private Plans: CMS, along with the Departments of Labor and Treasury, is requiring that most private health plans and issuers cover the COVID-19 vaccine and its administration, both in-network and out-of-network, with no cost- sharing during the public health emergency (PHE). Current regulations provide that out-of-network rates must be reasonable, as compared to prevailing market rates, and reference the Medicare reimbursement rates as a potential guideline for insurance companies. In light of CMS’s increased Medicare payment rates, CMS will expect commercial carriers to continue to ensure that their rates are reasonable in comparison to prevailing market rates. 

    Uninsured: For individuals who are uninsured, providers may submit claims for reimbursement for administering the COVID-19 vaccine to individuals without insurance through the Provider Relief Fund, administered by the Health Resources and Services Administration (HRSA).

    More information on Medicare payment for COVID-19 vaccine administration – including a list of billing codes, payment allowances and effective dates – is available at Vaccine Shot Payment.

    More information regarding the Centers for Disease Control and Prevention (CDC) COVID-19 Vaccination Program Provider Requirements, and how the COVID-19 vaccine is provided at 100% no-cost to recipients is available at Provider Support.

    Information on the COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing, Treatment, and Vaccine Administration for the Uninsured Program is available at Covid-19 Uninsured. 

    To view the complete Centers for Medicare & Medicaid Services (CMS) announcement, click Vaccine Payments. 

    To contact CMS Media Relations: (202) 690-6145 or CMS Media Inquiries.

    ClaimCare Blue web

    About ClaimCare ®                        

    ClaimCare has 30 years of medical billing experience. We have an established 100% USA-Based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

    ClaimCare has once again been named a “Top 10 Medical Billing and Coding Company.” The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this 2019-2020 recognition. 

    For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website. We can assist your practice and/or facility in numerous ways, including complete certification processing.


    100% USA-Based HIPAA-Compliant Medical Billing Company



    Tags: medical billing, medical billing process, COVID-19 Medical Reimbursement, COVID-19, COVID and the law

    What You Need to Know Before Hiring a Medical Billing Company

    Posted by Carl Mays on Tue, Jan 14, 2020 @ 11:00 AM

    What You Need to Know Before Hiring a Medical Billing CompanyClaimCare Medical Billing, 100% USA-based, has once again been named a ‘Top 10 Medical Billing and Coding Company.’ The honor this time comes from MD Tech Review. The magazine’s Augmenting Medical Billing and Coding Operations article presents solid reasons why ClaimCare has been chosen for this recognition.

    Finding the right medical billing company can be challenging for practices or facilities that are dissatisfied with their current billing situation - or for those just starting up new practices or facilities. At the same time, medical billing and coding remains one of the most important aspects of medical- provider organizations.

    It is a proven fact that has been documented by medical practices and facilities, and by various patient surveys, many patients will switch healthcare services due to their discontent with an in-house or outsourced billing staff. And, the discontented patients often go online to air their frustrations, as well as share their dissatisfaction with family and friends. Obviously, this proves to be very costly to medical providers.

    Medical billing and coding is an ever-changing and always demanding job that requires highly-knowledgeable and laser-focused professionals. This is why ClaimCare rises above the basics of medical billing and coding with a mission statement that reads: “To collect the maximum for your practice as fast as possible while helping to alleviate costs and hassle for your organization.”

    Regardless of whether you currently have in-house or outsourced medical billing, it is vital to ensure your service contains the absolute basics needed to please the government, keep the patients content and the cash flow coming. If you do choose to outsource your service to any medical billing company, we recommend you pay attention to these 4 tips:

    Tip No.1: Check to see if the company is HIPAA compliant

    “If you think compliance is expensive, try non-compliance.”

    There is a good reason why the Government sets rules of compliance for various organizations. This is to protect consumers from unreliable service providers, including medical billing companies that have an unsecured online infrastructure.

    Thus, it is important to check to see if the medical biller you are dealing with, or want to deal with, is HIPAA compliant. If not, then it is best to look for someone that is compliant to the HIPAA rules and regulations.

    Tip No 2: Consider the company’s medical billing experience

    “Claiming is one thing, but proving is another thing.”

    Any company can easily say they offer the best services. But how can you know if they do?

    Their years of service in the industry says a lot about their work. After all, an organization cannot last long unless they deliver exceptional medical billing services to their clients. Thus, it is extremely important to know how long they have been in the industry.

    Tip No. 3: Ask about the company’s reporting system

    “All technologies are not equal.”

    One thing that sets medical billing companies apart from one another is the additional features they deliver, such as their reporting system.

    While some companies may just give you log-in details so you can process your medical bills, others will include a monthly, weekly, or real-time dashboard report. Thus, it is best to choose a company that can give everything you need to make your practice more efficient. This includes:

    • 24/7 access to your medical billing data
    • Automated insurance verification
    • Easy to use dashboard reports
    • Electronic medical record software
    • Practice analytics and recommendations
    • Practice management system
    • Scheduler

    Tip No. 4: Confirm the company’s client reviews

    Reviews are a gold mine when looking for the best medical billers. However, don’t simply believe everything you read online or hear from the company.

    Do some investigation. Contact these clients to inquire personally about the services provided to them by their medical billers. This ensures you choose an honest and reliable medical billing company.



    There are other factors you will need to consider when choosing the right medical billing company for your practice or facility. This includes the cost, staff, and contract issues you will need to clarify with them. However, it is vital that you begin by considering these 4 tips as the first step to help you decide if the medical biller will fit your needs.

    Do you need to learn more about medical billing? Subscribe to our blog to receive regular updates, tips, and recommendations.

    About ClaimCare

    ClaimCare has 30 years of medical billing experience. We have an established 100% USA-based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

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

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

    Tags: medical billing, best medical billing companies, medical billing process

    4 Medical Billing Errors Preventing a Healthy Patient-Provider Relationship

    Posted by Carl Mays on Thu, Dec 19, 2019 @ 02:00 PM

    4 Medical Billing Errors Preventing a Healthy Patient-Provider RelationshipDo you know that “surveys consistently demonstrate that patients prioritize both the interpersonal attributes of their providers and their individual relationships with providers above all else?” This is the statement made by Kurt Strange, an expert in family and health systems in one of the articles published in Harvard Business Review.

    This video from Advent Health Florida further elaborates on this:



    A healthy patient-provider relationship that develops in the office can quickly be affected negatively if after the treatment the patient receives a medical bill that contains errors.To avoid this from happening, it is important that physicians and staff keep in mind the following common errors in medical bills that can hurt a good office-developed relationship.

    1. Medical Code Mismatch

    Any mismatch with your codes can cause rejection or denial of your patient’s medical claim. Healthcare in America reveals just how much these medical billing errors cost:

    “Most patient billing errors happen due to technology or a staff member entering an incorrect diagnostic code onto the bill. This becomes more common on bills that total more than $10,000 or more. According to credit agency Equifax, those bills often come with errors totaling more than $1300.”

    With a discrepancy amounting to more than $1300, there is no wonder your patient becomes dissatisfied. Thus, it is essential that your medical billers enter the right codes. Otherwise, be prepared to face the fury of your patient or the patient’s relatives.

    2. Duplicate Medical Billing

    As of July 2, 2018, all CMS-1500 hard copy claims should not have any duplicate ICD-10-CM diagnosis code within item 21. This is the directive issued by Medicare. Thus, any claims containing duplicate diagnosis codes will be returned as unprocessed by the Medicare Administrative Contractors (MACs) and the Durable Medical Equipment (DME).

    With this being implemented, the frequency of duplicate medical billing is expected to decrease, if not eliminated. The outcome is a more satisfying patient experience.

    3. Upcoding

    In 2018, Prime Healthcare Services was charged $65 million to settle a federal whistleblower lawsuit that accused the fast-growing California hospital chain of engineering a wide-ranging Medicare fraud scheme. Included in this lawsuit is the issue of upcoding, a medical billing error wherein services are added to the patient’s medical bill even if these services are not executed.

    Upcoding may happen for two reasons: accidentally or intentionally. Whatever reason it may be, any patient who sees unnecessary treatments included in their medical bill will most definitely direct anger towards your billing staff.

    Therefore, always perform due diligence before issuing a medical bill. Double check the codes you have entered.

    4. Incorrect Entry of Patient Information

    Sometimes, it’s the small things that can be so annoying, such as a misspelled last name or incorrect policy ID number. These could have been easily checked to avoid any claim rejection or denial.

    So, be extra careful and meticulously check all the information you’ve entered into your system. Not only will this save your practice time and money, but it will also free you from heaps of frustration due to increasing patient complaints.


    Billing errors should hurt the provider-patient relationship. Ensure patients are well treated during and after check-in. Do so by handling their medical bills more efficiently through a skilled and reliable medical billing company. Learn more tips and advice related to medical billing and claims processing. Subscribe to our blog, today.

    About ClaimCare

    ClaimCare has more than 29 years of medical billing experience. We have an established 100% USA based medical billing team that has been assembled through a thorough pre-employment screening. All personnel participate in on-going training and strong process management to ensure they deliver only the highest quality medical billing services to clients.

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

    Healthcare Tech Outlook named ClaimCare as one of the nation’s"Top 10 Medical Billing Companies" in 2019. For more information, contact sales@claimcare.net, or phone toll-free at (855) 376-7631, or visit the ClaimCare Medical Billing Company website.





    Tags: medical billing, medical billing process

    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

    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) 376-7631 to learn more about the services we deliver.

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

    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

    Impact of Proposed 2019 Medicare to Medical Billing of Ambulatory Surgical Center Services

    Posted by Carl Mays on Thu, Aug 15, 2019 @ 02:00 PM

    Impact of the Proposed 2019 Medicare to the Medical Billing of Ambulatory Surgical Center ServicesLast July, the Centers for Medicare and Medicaid Services (CMS) released a proposed payment rule for the Ambulatory Surgery Center Association (ASCA) and Hospital Outpatient Departments (HOPDs) for 2019. These updates address several long-requested ASCA priorities, which include the following:

    • Threshold for device intensive surgeries and clinic cost visits
    • ASC covered procedures performed in ASC setting
    • Quality Reporting Program

    This article discusses how these points are addressed and the impact on your physician billing and ASC services.

    3 Major Changes for ASC Services Based on Proposed 2019 CMS Payment Rule:

    The changes to the CMS Payment Rule aim to deliver these ASC physician billing advantages:

    1. Lower threshold for device intensive surgeries and clinic cost visits.

    The ASC has long been requesting a lower threshold compared to the current 40 percent applied on its standard OPPS APC rate-setting methodology. Through the Proposed 2019 Medicare Changes, this can now become a reality.

    Under the proposed change, the threshold will now be reduced to 30 percent, thus allowing high-cost devices to be better recognized in ASC settings. Moreover, clinic visit costs would also be reduced from approximately $116 with a copayment of $23 to just $46 with a copayment of only $9. This means an estimated savings of $14 for each off-campus department visit of patients and a $760 million savings for Medicare in 2019.

    2. Expanded ASC Covered Procedures List (CPL).

    Part of the proposed 2019 changes entails the inclusion of "surgery like" procedures that are outside the current CPT surgical range (10000 - 69999) to the ASC CPL. However, these surgeries would be limited to the following conditions:

    • Accepted surgical procedures that are expected NOT to pose any significant risk to the safety of the beneficiary (patient)
    • Does NOT require an overnight stay when performed in an ASC
    • Separately paid under the OPPS

    If implemented, this would lead to a 2% increase rate for ASC, which is based on the combined 2.8% inflation update reported by the hospital market basket and the 0.8% mandated reduction by the ACA. However, it should be noted that this 2% increase will be code-specific, thus it will not be applied to all ASC procedures.

    3. Easier ASC Quality Reporting Program.

    Under the proposed 2019 Medicare, eight measures required by the ASC Quality Reporting (ASCQR) Program for their CY 2020 and CY 2021 payment determinations will be removed. This includes the following:

    • Influenza Vaccination Coverage Among Healthcare Personnel (CY 2020: ASC-8)
    • Patient Burn (CY 2021: ASC -1)
    • Patient Fall (CY 2021: ASC -2)
    • Wrong Site, Wrong Side, Wrong Patient, Wrong Procedure, Wrong Implant (CY 2021: ASC -3)
    • All Cause Hospital Transfer/Admission (CY 2021: ASC-4)
    • Endoscopy/Polyp Surveillance Follow-up Interval for Normal Colonoscopy in Average Risk Patients (CY 2021: ASC-9)
    • Endoscopy/Polyp Surveillance: Colonoscopy Interval for Patients with a History of Adenomatous Polyps (CY 2021: ASC-10)
    • Avoidance of Inappropriate Use; and voluntary measure Cataracts - Improvement in Patient's Visual Function within 90 Days Following Cataract Surgery (CY 2021: ASC-11)

    This is because ASC's have demonstrated an outstanding performance in preventing serious adverse events. Thus, CMS has found it unnecessary to collect these above-mentioned data measures from them.

    Conclusion: Who would benefit from these changes?

    Ultimately, these proposed policy changes aim to create a better patient-centered healthcare system by providing greater:

    • Price transparency
    • Interoperability
    • Significant burden reduction

    This results in several benefits not only to the patients but also for both ASCs and hospitals. Patients are given more health care options at a minimal cost while ASCs and hospitals can operate with better flexibility.

    Would you like more updates about the Proposed 2019 Medicare and its impact on your physician billing? Subscribe to our blog to remain posted or call us toll-free at (855) 376-7631 today.

    About ClaimCare

    ClaimCare is composed of skilled and knowledgeable medical providers, practice managers, certified coders, experienced business professionals, and engineers. This is to guarantee you receive effective and efficient team physician billing services all year round.

    Tags: medical billing, medical billing services

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