Medical Billing 101 - How To Stay Compliant And Efficient

Medical billing and coding go hand-in-hand when dealing with medical insurers, patients, and legal and regulatory requirements within healthcare businesses.

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What is medical billing and coding?

What is medical billing and coding?

Medical billing and coding tend to go hand-in-hand when dealing with medical insurers, patients, and legal and regulatory requirements within healthcare businesses. Although separate processes, both billing and coding are integral to securing payments from healthcare services to providers and insurers. 

Medical coding concerns translating healthcare information about a patient’s condition, diagnosis, prescriptions, and other equipment or services used into a universal code. According to international coding standards, the regulations are specified and are taken from any medical record, such as physician notes, testing, and examinations. If used correctly, they can effectively inform and allow for appropriate medical billing procedures. 

On the other hand, medical billing ensures that insurers reimburse patients or healthcare facilities with the correct amount. Medical billers are responsible for ensuring that legal standards are fulfilled and that claims are free from errors. Medical billers also have the task of following up on denied claims, as well as unpaid claims.

Some healthcare business platforms, such as Carepatron, provide processes that enable simple medical billing and coding for healthcare professionals. However, regardless of your decision to automate, knowing medical billing and coding could prove immeasurable for your practice.

Importance of accurate and compliant billing

Because of continual law developments, it can be challenging to keep up with regulations and ensure that you’re constantly being compliant. It is straightforward to miss information or forget specific processes without intending to, and as a result, we’ve provided medical billing 101 information to guide your medical billing solutions.

  • Financial protection - Billing and coding can have significant financial consequences for your health practice if not done correctly. Inaccuracies can lead to not receiving the total amount you’re entitled to from patients or insurers. Even if this is just a tiny inaccurate calculation each time, this can add up to losing thousands of dollars for your healthcare practice. Financial miscalculations could also lead to claim delays in having to go and fix these mistakes, not to mention legal issues that may arise. Taking the time to implement medical billing management and protocol systems can secure the financial protection of your healthcare clinic and prevent adverse events from happening. 
  • Patient protection - Because medical coding identifies the exact treatments and diagnosis of a patient, this documentation is used as part of their medical records. Thus, it is of utmost importance that the medical information from evidence such as lab results, x-rays, and medications, are accurate and coded correctly. Incorrect translation of information can put the patient’s health at risk and significantly reduce the quality and standard of care. 
  • Future forecasting - Not only does accurate billing allow for accurate financial reimbursement, but it also allows your practice to forecast for the future. Medical billing information can be used to analyze data concerning costs and revenue, which can help you to make informed business decisions.
Importance of accurate and compliant billing
Who sets the medical billing compliance rules in the US?

Who sets the medical billing compliance rules in the US?

We hear all these rules surrounding compliance regarding medical billing and medical coding, so naturally, you may wonder who sets such guidelines. Well, it’s several different players, including:

  • The Centers for Medicare and Medicaid Services (CMS) concern both the Medicare and Medicaid government healthcare programs. While Medicare originally served to provide healthcare to the elderly, their access extended to those with disabilities, needing transplants or prescription coverage. It is important to note that their policies change frequently and that procedures, such as removing skin growth, are only covered if applicable to specific rules. Because of their widespread influence, CMS tends to set the primary standards for medical billing compliance rules. 
  • The Office of Inspector General (OIG) oversees programs that run through the Department of Health and Human Services (HHS) and center their operations around identifying fraud, waste, and abuse in federal programs such as Medicare. The audit and track the spending of government funds and essentially moderate how taxpayer funds are used. 
  • Insurance companies - These individual players create their policies and procedures available for the general public to review. They may follow Medicare rules for payment, but they don’t necessarily have to follow them. Insurance companies tend to establish and employ their processing policies and follow their outlined rules. Therefore, medical billers and coders must be aware of this when dealing with specific insurance businesses.

Six tips to stay compliant and efficient in the medical billing space

With the abundance of overwhelming information, it can be difficult to decipher information and pick out what is relevant to your healthcare practice. As a result, we have compiled a list of 6 helpful tips for medical billing systems to ensure that your physician and healthcare billing is accurate and compliant. 

  • Promptly follow-up rejected claims - A rejected claim has not been processed due to errors, and a denied claim has been processed and contains violations or errors that prevent payables. Rejected claims can be edited and resubmitted, whereas a denied claim must be appealed, which is more costly and time-consuming. Handling them quickly by checking for errors and clarifying problems promptly will minimize resubmission times and allow more time for other business practices. 
  • Establish clear collections - Patients need to be informed of what is expected when they pay their debts. Reminding them of their obligations minimizes patient misunderstandings and reduces the risk of feigning ignorance in legal cases. Their information should also be collected with their ID and verified addresses, and payment should be collected upfront to avoid paperwork. Co-pay plans need to be confirmed, as well as eligibility. 
  • Have good claim management - Submitting claims can be a complicated process, and claims based on incorrect billing can lead to a weeks-long process of submission, rejection, editing, and resubmission. Considering 80% of medical bills contain errors, it is essential to spend time ensuring they’re correct. This means having accurate patient, provider, and insurance information, excellent documentation with clear coding, and an Explanation of Benefits (EOB) attached. 
  • Be open to improvement - The healthcare climate undergoes continual developments, and tracking performance can help identify issues and highlight improvements to be made. Keeping informed on changing medical billing rules and providing education on protocols where needed can elevate the quality of your healthcare practice. This is in addition to identifying problem accounts such as late or declined payments. 
  • Outsource appropriately - Sometimes, it’s okay to lag and recognize that having others who are more skilled to manage aspects of medical billing is a good thing. Outsourcing dedicated specialists can mean that they are specifically trained in ensuring coding and billing is correct, which saves time for other business responsibilities. Having trained staff means claim submissions can be faster, doctors and nurses can focus on their patients, and your practice complies with up-to-date standards. 
  • Reduce coding mistakes - Having incorrect, missing, or mismatched codes can lead to a lengthy submission process to edit and resubmit to the clearinghouse. Common mistakes usually include non-specific diagnosis codes and incorrect modifiers, upcoding where more expensive procedures are added, or under coding with less costly services. Double-checking can prevent errors from occurring and ensure your practice stays compliant. 

A great way to ensure you’re fulfilling the needs of your business is to work with healthcare business software, such as Careaptron, which provides resources concerning medical compliance that you can count on. This way, you can make sure medical coding is an accurate and easy process, and it serves as a surefire way for you to stay on top of things within the healthcare space. 

Conquering medical billing at your business with Carepatron

With the constantly changing rules and standards, medical billing can be a complicated and costly process. Time spent editing and resubmitting rejected or denied claims due to coding errors can mean less time is spent with patients, which can be tedious for your practice. To avoid this, Carepatron can support the medical billing process by providing software that seamlessly incorporates what you need to include and what codes are appropriate to use. This way, you can ensure your patients are receiving the highest level of care. 

Medical billing is an essential process that you need to nail; however, following these tips will significantly guide you in the right direction. Being able to master medical billing can be a learning curve, but harnessing it right will ensure the success of your business. 

Further reading:

Six tips to stay compliant and efficient in the medical billing space

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