MEDICAL BILLING

US Medical billing is a process, in which we work for US doctors to get their payment cleared from US
insurance companies in a legal way.

Flow chart of Medical Billing:-

DEPARTMENT OF MEDICAL BILLING

1. Billing Department :- This department works on billing of claims to insurance.

2. Coding Department :- This department works for doing coding for Diseases and Treatment.

3. AR Department :- AR department works for unpaid claims by insurance. Full form of AR is Account
Receivable.

4. Payment Posting Department :- This department works to post the payment on paid claim and to post
the denial EOBs on a perticular claim received by insurance.
 ABBRIVATIONS

1. HIPPA :- Health Insurance Portability and Accountability Act. It is a rule in US Medical Billing, in which
we can not disclose patient's medical condition with anyone without patient's permition.

2. HCFA :- Health Care Financing Administration. It is a claim form on which claim files to insurance. In
short we say this HCFA 1500.

3. CPT :- Current Procedural Termonology. These are five digit numeric or alpha numeric codes which
used to coding for Treatment. i.e 99204, 78546 etc.

4. ICD :- International Classification of Diseases. These are the codes which used for diseases, we also say
to these code as DX codes.

5. DOS :- Date of Service. This is the date on which patient get treatment from doctor. We also say to
doctor as provider in Medical Billing lenguage.

6. POS :- Place of Service. Place of Service means the place of treatment like Hospital, doctor's clinic,
patient's House etc.

7. EOB :- Explanation of Benefits. This is the document, on which insurance mention the datails of
payment or denial of a claim. Insurance send this document to provider and patient both.

8. COB :- Co-Ordination of Benefits. It is process through which patient decide that which insurance will
pay as primary and which will pay as secondary. In other words we can say that the choice of patient to
choose primary and secondary insurance is know as COB.

9. SSN :- Social Security Number. This is a unique nine digit number which is assigned by US government
to every citizen of USA.

10. PCP :- Primary Care Physician. This is first doctor who takes first responsibility to treat the patient.
This doctor also called Reffering doctor and Gate Keeper. Also this doctor referres patient to specialist if
patient needs treatment from specialist.

11. NPI :- National Provider Identifier. This is a 10 digit numeric number which is assigned by US
government to doctors for their identification. It important to billing claims and insurance calling.

12. Tax ID:- It is 9 digit unique number which is assign by US government to every provider. It is
mendatory for US calling and claim billing.

13. CMS - Centers for Medicaid and Medicare Services. Federal agency which administers Medicare,
Medicaid, HIPAA, and other health programs. Formerly known as the HCFA (Health Care Financing
Administration). You'll notice that CMS it the source of a lot of medical billing terms.

14. DME - Durable Medical Equipment . Medical supplies such as wheelchairs, oxygen, catheter, glucose
monitors, crutches, walkers, etc, comes under Durable Medical Equipment.

16. EFT- Electronic Funds Transfer. An electronic paperless means of transferring money. This allows
funds to be transferred, credited, or debited to a bank account and eliminates the need for paper checks.
17. ERA - Electronic Remittance Advice. This is an electronic version of an insurance EOB that provides
details of insurance claim payments. These are formatted in according to the HIPAA X12N 835 standard.

18. ABN- Advance Beneficiary Notice. It is form sighned by patient, in which it is mentioned that if
Medicare will not pay for any service, then patient will have to pay for that service.

19. HCPCS- Health Care Financing Administration Common Procedure Coding System.

20. PTAN(provider transation number):- It is a unique number which only has Medicare and it is
mendatory for Medicare calling, when we call to Medicare IVR as for PTAN then forward call further.

BASIC TRAINING MATERIAL

1. Clearinghouse :- This is a service that transmits claims to insurance carriers. Prior to submitting claims
the clearinghouse scrubs claims and checks for errors. This minimizes the amount of rejected claims as
most errors can be easily corrected. Clearinghouses electronically transmit claim information that is
compliant with the strict HIPAA standards

2. Beneficiary - Person or persons covered by the health insurance plan.

3. Clean Claim - Medical billing term for a complete submitted insurance claim thaT has all the necessary
correct information without any omissions or mistakes that allows it to be processed and paid promptly.

5. Co-Payment or Co-pay :- This is the small dollar amount which patient has to pay to provider on every
visit. This is diffrent for PCP and Specialist.

6. Co-Insurance:- This is amount which is left over by primary or secondary insurance after paid the claim
which is paid by patient for patient's secondary or tertiary insurance.

7. Deductible :- Deductible is a amount which patient has to pay to Provider/Insurance. Untill patient will
not met their deductible, insurance company do not start to pay benefits of patient. Medicare and
Commercial insurances starts in January in each year while Tricare starts in October in each year.

7. Primary Insurance :- This is the insurance company which process claim first.

8. Secondary Insurance :- This is the insurance which process claim on second number after the
processing of primary insurance.

9. Tertiary Insurance :- This is the insurance which process claim on third number after the processing of
primary and secondary insurance.

10. Claim number# :- Claim number is a number which is provided and decided by insurance company
for perticular claim so that insurance and billing company can identify the claim. It is a unique number.
We also called claim# as ICN(insurance claim number).

11. UB04 - Claim form for hospitals, clinics, or any provider billing for facility fees similar to CMS 1500.
Replaces the UB92 form.
12. Aeging/Allocation :- Aeging means that the work assigned by supervisor on which we need to work.
It is assigned on Excel sheet.

13. In Patient :- In Patient means the patient who remains in Hospital more than 24 hours.

14. Out Patient :- Out Patient means the patient who do not remains in Hospital for 24 hours.

15. New Patient :- New patient means the patient who is taking service for first time or who is taking
services after 3 years. CPT codes for New Patient starts from 99201 to 99205.

16. Established Patient :- This means the patient who takes services on regular bases or taking service
within 3 years. CPT codes for New Patient starts from 99211 to 99215.

18. Fee Schedule - It means the amout which is allowed by insurance for a perticular CPT code or
service.

19 Charge Amount/Billed Amount :- It means that the amount which is billed by provider on claim for a
perticular service(CPT).

20. Allowed Amount :- It means the amount which is allowed by insurane for a perticular CPT. It is
diffrent to insurance to insurance and state to state.

21. Capitation :- Capitaion means a contract between provider and insurance company. In this contract,
insurance offers to provider a lump sum amount for their patients in the area of provider after that their
patient takes services for so many time or not take any service.

22. Offset or Recoupment :- If insurance get pay incorrectly on any claim, then they ask to provider to
refund the paid amount or directly adjust that paid amount in next payment of provider that process is
called Offset or Recoupment.

23. In Network Provider/Participitating provider/Contrated provider :- These are the providers who has
contract with insurance company that what amount will insurance allowed, provider will accept that as
full and final payment and the balance between the charge amount and allowed amount will be write
off. They gets more patients.

24. Out of Network Provider/Non Participitating provider/Non Contrated provider :- These are the
providers who do not have the contract with insurance as In Network provider has. They need their
complete billed amount whether insurance pay or patient. They gets less patients.

25. Contractual Adjustment :- It means the amount which is not paid by insurance like the diffrence
between the charge amount and allowed amount is called as contractual adjustment because this
amount adjust as per In network contract of provider.

26. Timely Filing Limit:- We also called Timely Filing Limit as TFL. It is the time duration in between
billing company has to file claim to insurance on behalf of provider. It is counts from DOS. Also if we do
not file claim to insurance within their TFL, insurance will deny that claim for Untimely Filing. Some
insurance's TFL are: (Medicare 365 days), (BCBS 120 days), (Aetna 120 days).

27. Appeal:- When we get to know that the denial on claim is incorrect or we do not agree on insurance
denial. Then we send a written request to insurance for again processing of claim. This complete process
is called appeal.
28. Appeal Limit:- Appeal limit is the time duration of insurance under which we need to file a written
request to insurance against the insurance denial. It always calcuated from date of denial.

29. Patient's Eligibility:- Patient's eligibility means that patient's policy is active on that DOS or not on
which is took services.

W9 Form:- This is a form, which insurance ask from provider to update his facility address on which
insurance release the check.

30. Modifiers :- As the name implies a modifier will modify a service / procedure or an item under
certain circumstances for appropriate reimbursement. Modifiers may add information or change the
description according to the physician documentation to give more specificity for the service or
procedure rendered. Appending of an appropriate modifier will effectively respond to reimbursement.

Some Imprtant Modifiers are :

Modifier -26 Professional Component :- It is used for reading a medical report like X-Ray.

Modifier -50 Bilateral Procedure :- Modifier 50, is used to report diagnostic, radiology and surgical
procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

Modifier -51 Multiple Procedures :- Modifier 51 designates multiple procedures that are rendered at the
same operative session or on the same day. Modifier -51 (multiple procedures) must be used to indicate
instances when multiple procedures, other than E/M services, physical medicine and rehabilitation
services, or provision of supplies (e.g., vaccines), are performed at the same session by the same
provider.

Modifier -59 Distinct Procedural Service :- It is use to unbulded the service with other.

Modifier -25 Significant, Separately Identifiable Evaluation and Management Service by the Same
Physician on the Same Day of the Procedure or Other Service :- It is use for unbuled or EnM codes.

Modifier -76 Repeat Procedure by Same Physician.

Modifier -77 Repeat Procedure by Another Physician.

Modifier - TC Technical Component :- It is use for Technical component like X-Ray machine, Untrasound
machine DME etc.

FEDERAL INSURANCES(Government insurances)

1. MEDICARE :- It is the largest federal insurance in USA which has own guidlines and fee schedule. It
pays the 80% of allowed amount applies 20% as co-insurance.

2. MEDICAID :- It is the second large federal insurance in USA which always pay for people who are
below powerty line i.e extremely poor people. It renews on monthly basis.

3. WORKERS COMPENSATION(WC) :- This is also federal insurance in USA which pays for the workers
who injured on their work. It always pays 100% of their allowed amount. Injury date in mendatory to bill
the WC claim and they allows on claim# for one patient and consider the claim# as their member ID.
4. NO FAULT INSURANCE :- No Fault Insurance, this is the insurance which pays for the auto accident
cases. Injury date is also mendatory in this insurance. They also consider their claim# as member ID and
assign one claim# for one patient.

5. VA(Veterans Administration) :- This insurance is also a federal insurance which pays for active US
army at VA medical centers and outpatient clinics located throughout the country.

COMMERCIAL INSURANCES

There are so many private insurances in USA which are known as Commercial Insurances. Some big and
common insurances are as below:

1. BCBS(Blue Cross Blue Sheild), 2. UHC(United Health Care), 3. Aetna, 4. Cigna, 5. Humana, 6.
Magnacare, 7. Qualcare, 8. Wellcare, 9. UMR, etc.

MEDICARE'S ELIGIBILITY

Medicare is only eligible for below patients:

A. Patient should be 65 years old or above 65 years.

B. Patient should be permanet kidney failure.

C. Patient should be suffered from ESRD(End Stage Renal Disease)

D. Patient should be permanent physically disabled.

PARTS OF MEDICARE

Medicare has four parts: Part A, Part B, Part C, Part D

1. Part A:- provides inpatient/hospital coverage.

2. Part B :- provides outpatient/medical coverage.

3. Part C :- offers an alternate way to receive your Medicare benefits (see below for more information).

4. Part D :- provides prescription drug coverage.

MEDICAID'S ELIGIBILITY

Medicaid is only for the people who are below powerty line(extremely poor). It renews on monthly basis
automatically and we can not sent any bill to patient of his/medical services if patient is active with
Medicaid except of non covered service.

QMB Plan of Medicaid:- QMB means Qualified Medicare Beneficiery in this plan Medicaid is only covers
Medicare Part B's Premium, means to say that Medicaid pays the premium on behalf of patient and if
Medicare left any patient's responsibility like Co-insurance, Co-pay or deductible, balance amount of that
will be adjust.

SLMB Plan of Medicaid:- SLMB means Specified Low income Medicare Beneficiery. In this plan Medicaid
only covers Medicare part B's deductible.

Medicaid SPENDOWN:- Spend down means that patient meet all eligibility requirements for Medicaid
except for income. Patient's spend down amount is the amount by which patient's monthly income
exceeds the Medicaid allowance for living expenses. Patient's caseworker sends a letter called the Spend
Down Notice. Patient need to spend spend down amount only on medical expenses.

MANAGED CARE PLANS

Managed care plans are a type of health insurance. They have contracts with health care providers and
medical facilities to provide care for members at reduced costs. These providers make up the plan's
network. How much of your care the plan will pay for depends on the network's rules.

There are three types of Manged Care Plan

1. HMO(Health Maintanance Organization) This plan only pays for in network providers. Referral is
always needed in this plan. Patient first need to meet PCP for service and if require then PCP will refer
patient to specialist. It pays on behalf of Medicare and Medicaid. It's premium is always less

2. PPO(Preferred Provider Organizations) This plan also pays on behalf of Medicare. In this plan patient
can visit directly to PCP or Specialist. No need of referral in this plan. It's premium is always higher than
HMO.

3. POS(Point of Service) This plan is the combination of HMO and PPO plan. In this plan if patient goes
first visit to PCP then referral needed, if patient directly visit to specialist, then no need of referral.

CORRECTED CLAIM

When we do any correction in the billing of claim like changing of CPT, DX, Charge amount or any other
information that billing called as Corrected Claim. Need to take frequency code 7 in software when
submitting corrected claim and need to write Corrected Claim in box# 19 of HCFA 1500. Important note:-
we never bill corrected claim to Medicare, Medicaid and VA(Veterans Administration).

Place of Services

11:- Office Visit

12:- Patient's home or Location, other than a hospital or other facility, where the patient
receives care in a private residence.

21. Inpatient Hospital

22. Out Patient Hospital.

24. Ambulatorty service

31. Skilled Nursing Facility:- A facility which primarily provides inpatient skilled nursing care and
related services to patients who require medical, nursing, or rehabilitative services but does not
provide the level of care or treatment available in a hospital.

32. Nursing Facility

34. Hospice

That's it these are the place of services about which i know.

MSP:- MSP means Medicare Secondary Payer, and Medicare will be secondary in following conditions:

1. If patient has WC or No Fault insurance as primary.

2. If patient has Employer group insurance as primary.

What Is Medigap Insurance/Medicare's supplimental plan?

Medigap, also called Medicare Supplement Insurance, These are commercial insurances which covers
Medicare's lest over balance like Dedutible, Co-insurance and Co-pay. Also if any service Medicare not
cover, supplimental plan also not cover that service.