Comprehensive Health Insurance Billing, Coding, and Reimbursement Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Chapter 9 Physician Medical Billing
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms The patient information form is completed by a new patient at registration. The assignment of benefits form is signed by the patient or guarantor so that the physician will be paid directly by the insurance carrier.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Medical Claim Forms The release of information ensures that information will only be released to authorized entities. The verification of benefits form with complete documentation is handy if claim is denied.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills Contain ICD-9-CM and CPT codes for services office routinely provides Individualized to meet specific needs of the practice Printed by medical office specialist, attached to chart, and follows patient through visit
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Superbills Also called encounter forms, charge slips, or routing slips Source document for entering patient data into computerized system
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims Claims are submitted on paper or optically scanned and converted to an electronic form by the insurance company. Claim attachments are added to the paper claim if additional information is required.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims Electronic claims or electronic media claim (EMCs) are submitted via central processing unit (CPU). Electronic form advantages include lower cost, fewer rejected claims, and faster payment.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Insurance Claims Electronic form disadvantages include disrupted transmission and inability of some billing programs to create electronic attachments. Dirty claims have missing or incorrect data.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500 The form was developed by Centers for Medicare and Medicaid Services to accelerate billing process. Patient and insured information is in form locators 1–13.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500 Physician and supplier information is in form locators 14–33. Specific guidelines are according to payer and state and local levels.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes HIPAA Requirements Transaction and code sets Uniform identifiers Privacy Security
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes CMS-1500 Instructions Section I form locators 1–13 include patient and payer information. Section II form locators 14–33 include physician and supplier information. Claims without errors or missing information are “clean claims.”
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers Types of numbers used are state license numbers, employer identification numbers, and tax identification numbers. NPI or National Provider Identification will be issued by Medicare and will replace identification numbers.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Physician Identification Numbers Referring physician (form locator 17a) Ordering physician (form locator 17a) Performing physician (form locator 24k) Billing entity (form locator 33)
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Delayed or Rejected CMS-1500s Problems are due to incorrect or missing information. There are solutions to prevent reoccurrence of problems and delayed or denied claims.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims Secondary insurance covers a person in addition to primary policy. Supplemental insurance, usually a Medigap policy, supplements Medicare payments. Coordination of benefits occurs so that the total payment does not exceed 100% of charges.
Copyright ©2009 by Pearson Education, Inc. Upper Saddle River, New Jersey All rights reserved. Comprehensive Health Insurance: Billing, Coding, and Reimbursement Deborah Vines, Elizabeth Rollins, Ann Braceland, Nancy H. Wright, and Judith S. Haynes Secondary Claims Rules exist for determining primary payer: –Lone policy –Policy in effect the longest –Birthday rule for dependent children –Certain rules regarding governmental policies –Refer to the list on pages 255–256