Medical Billers and Coders

Changes in healthcare regulations can significantly impact medical billing procedures in the United States. These regulations can come from federal, state, or local government entities and may affect various aspects of healthcare delivery, insurance coverage, and reimbursement. Here are some ways in which changes in healthcare regulations can impact Medical Billing procedures: Coding and Documentation Requirements: New regulations may introduce changes in the coding and documentation requirements for medical procedures and services. This can impact the way healthcare providers document patient encounters and submit claims. Billing and Reimbursement Rates: Healthcare regulations often influence reimbursement rates for medical services. Changes in regulations can lead to adjustments in the amounts that healthcare providers are reimbursed for specific procedures or services. This, in turn, affects the amounts billed to patients or insurance companies. Compliance and Reporting Requirement

Let's be honest, medical bills can tangle anyone's brain, even those working inside hospitals and clinics! Folks like doctors' office assistants and hospital staff handle internal billing daily, but even they can stumble into common mistakes that leave patients grumpy and paperwork piled high. Let's shine a light on these hiccups and equip you with some simple tips to navigate the world of bills with ease, making everyone's day a little brighter! 1.        Blind Trust in Automation: Automating billing processes streamlines workflow, but relying solely on technology can be a trap. Errors can slip through the cracks, leading to inaccurate bills and unhappy patients. 2.        Misunderstanding Insurance Lingo: Medical jargon and insurance codes can feel like a foreign language. In-house staff who aren't familiar with the nuances can interpret coverage incorrectly, leading to mismatched bills and frustrated patients. 3.        Lack of Communication: Op

  In the Final Medicare Physician Fee Schedule (MPFS) for 2022 issued on November 2, 2021, the Centers for Medicare and Medicaid Services (CMS) added five new CPT codes in the categories of Chronic Care Management (CCM) and Principal Care Management (PCM) and increased reimbursement for already existing codes in the same categories. These codes are like chronic care management services in that the work involves the establishment, implementation, revision, and monitoring of a care plan for a patient. However, principal care management focuses on a single condition (rather than two or more). In the year 2022, Medicare will accept CPT codes 99424, 99425, 99426, and 99427, and discontinue HCPCS codes G2064 and G2065. 2022 Revised Codes for Principal Care Management CPT 99424: Principal care management services, for a single high-risk disease, with the following, required elements: one complex chronic condition expected to last at least 3 months, and that places the patient at  signi

  As physicians, doctors, healthcare units, ASCs, and  medical billing and coding companies  observe this year’s passage of the newly laid  MACRA/MIPS  reporting rule, there are a lot of dilemmas about its positives and avoidance for the year 2018. However, it will be important to notice whether the final rule continues to trend toward value-based care. Also, given the intricacy and sweeping nature of QPP, it is yet to be seen whether or not positives and avoidances will alleviate administrative burden. Understanding the MACRA/MIPS Proposed Rule Experts, including those working in the government, who are keenly observing the scenario, have some important takeaways from the proposed rule: Around 34%-36% of physicians will be eligible for MIPS after all exclusions, although they make up 55%-58% of Medicare Part B charges. MACRA/QPP is an enormous piece of legislation. At its business end, it will eliminate the sustainable growth rate formula and replace it with a 0.5% annual rate

  EDI in medical billing helps doctor’s offices, hospitals, labs, pharmacies, and other healthcare facilities to communicate with each other. In today’s world of electronic claim submission, electronic data interchange (EDI) has become an essential component of medical billing processes. EDI enables healthcare providers and insurance companies to exchange crucial billing information efficiently and securely. This article will explore the details of EDI in medical billing, exploring its significance, working mechanism, and benefits in medical billing. What Does EDI Stand for in Medical Billing? EDI stands for electronic data interchange. In the context of medical billing, EDI refers to the electronic exchange of standardized healthcare transactions between healthcare providers and insurance companies. It involves the transmission of data in a structured format, allowing for seamless communication and streamlining of billing processes. Electronic Billing and EDI Transactions Electr

  Account Receivable (AR)  is one step that divides the reimbursement and claims; the older the claim gets the harder it becomes for claims to get reimbursed. For practice when AR slips below a certain level you either have a pretty large backlog to be sorted out, or you can see that it becomes impossible to tackle the day’s run-out without any futile results.   The major challenge is that in recent years the financial responsibility and medical care for patients have compounded but on the other hand, we see that the widespread reach of more and more products through new healthcare insurance exchanges has prompted higher deductibles or coinsurance for physicians. As physicians cope with unfamiliar issues with different insurance companies, the AR suffers dearly. Here are three factors you can look into to solve your AR pile-up mess. 3 Unknown Myths about AR Pile-Up Step up the insurance verification process The starting point of addressing AR issues is the first step of  Reven

  PAR and non-PAR Providers with Medicare The Center for Medicare & Medicaid Services (CMS) is a federal agency within the Department of Health and Human Services that manages and oversees the Medicare program for beneficiaries. Physicians are required to comply with numerous laws and regulations related to various aspects of their practice within the Medicare program. Each year physicians have the opportunity to review and modify their contractual relationship within the Medicare program. Participating providers are referred to as ‘PAR’ while non-participating providers are referred to as ‘Non-PAR’. Providers need to understand their options within the program to ensure proper reimbursement. The primary difference between being a PAR and a non-PAR Provider lies in how fees will be collected. The three Medicare contractual options available for physicians are as follows: Participating (PAR) providers can sign a participating agreement and accept Medicare’s allowable charges as

  The changing political trends have affected the way physicians are implementing changes in their functioning at work, be it at clinics or hospitals. Keeping up with the times is the need of the hour and hence never knowing which way the winds will blow, physicians should initiate certain goals that can help them ride the rough weather when it comes and sail through the smooth times. Here we shared information on Top Goals for Physicians to Implement In Their Facility So What Goals Can Physicians Implement? Based on a recent online research Toluna’s healthcare panel of 500 physicians revealed that nearly 9 in 10 respondents ranked “achieving work-life balance” as their most or second most-important resolution for 2017. This was followed by 69 percent who ranked “staying up-to-date with technology,” and 58 percent ranked “taking advantage of more leadership and training opportunities”. The latter two goals can help achieve the former and topmost goal of achieving a work-life balan

  Let’s always keep in mind that patients come with some problems that they hope will be solved quickly and without any hassles. So, how does one keep the patients happy? While keeping a smiling face makes good sense, giving the patients a great experience is an art in itself. Here are a few valuable tips that can help you do just that.  Outsourcing your medical billing can seem scary. The more empowered you are, the easier will be to make the right decision for your practice´s medical billing needs. In our webinar  “Five reasons to outsource your medical billing” , Health Prime´s Strategic Account Manager, Caroline Balestra, reviewed the main reasons to outsource your billing and some benefits for your medical practice. 5 Things About Better Medical Billing and Happier Patients Give them the right to have a better choice Being transparent is probably the first step in giving healthcare to patients in distress. Allowing them to make the right choice, or rather giving them the righ

  Importance of A/R Follow-up Medical billing is a complicated process that requires special skills in medical billing, coding, denial, and AR management from experienced and well-trained staff. The financial health and success of any medical practice are dependent on maintaining positive cash flow. In order to provide patient care and cover expenses, it’s important that payments are not delayed, lost, or denied. With the understanding of billing guidelines and a highly trained staff in place, you’ll start to reap the benefits of high first-pass acceptance rates and shorter billing cycles. But even when everything goes right, some claims will still be rejected or denied. The accounts receivable (A/R) follow-up team in a healthcare organization is responsible for looking after such denied claims and reopening them to receive rightful reimbursement from the insurance carriers. Even though these claims could be held up by simple mistakes, you will be surprised to know that over half of

  Understanding False Claims Act As a healthcare practice, you can typically submit claims to Medicare or Medicaid. Your claims are bills for goods you provide and services you conduct for patients. These federal health insurance programs cover the costs associated with your services. The False Claim Act is a federal law that makes it a crime for any person or organization to knowingly make a false record or file a false claim regarding any federal health care program, which includes any plan or program that provides health benefits, whether directly, through insurance or otherwise, which is funded directly, in whole or in part, by the United States Government or any state healthcare system. In other words, healthcare practices must not bill the government for things they did not do. Examples of false claims include billing for services not provided, billing for the same service more than once, or making false statements to obtain payment for services. Penalties under the False Clai

  Revised Role of Prior Authorization So far insurance carriers have been using prior authorization as a tool to control spending and promote cost-effective care. But in changing billing scenarios role of prior authorizations has changed drastically. There is little information about how often prior authorization is used and for what treatments, how often authorization is denied, or how reviews affect patient care and costs. As per the 2021 American Medical Association survey, almost 88 percent of providers characterized administrative burdens from this process as high or extremely high. Doctors also indicated that prior authorization often delays the care patients receive and results in negative clinical outcomes.  Another independent 2019 study concluded that research to date has not provided enough evidence to make any conclusions about the health impacts nor the net economic impact of prior authorization generally. This blog will explore the Revised Billing Updates for Prior Aut