1. Pulling back the Curtain: Understanding the medical billing process
Shirley Reitz, PharmD
August 10, 2016

2. Key Take Aways Medical billing is different from pharmacy billing
A provider = A provider = A provider
This is a new for the health plans as well
Success is possible
August 10, 2016

3. Pharmacy Claim ? Rx
Switch Vendor
PBM

4. Medical Claim ?
Billing Service
Clearinghouse Vendor
Payer

5. Pharmacy Billing Cycle

6. Medical Billing Cycle

7. Collection & Verification
Collect Patient Information
Verify Insurance in real-time
Revenue Cycle Management
Obtain additional documents
Obtain balance billing document
Gap 1
Patient Management
Need to determine insurance eligibility, schedule appointments, and collect patient information prior to or during visit

8. Medication Decision Making
Patient Care
History
Examination
Medication Decision Making
Utilize Pharmacists’ Patient Care Process to improve patient health and outcomes
Gap 2
Clinical Documentation
Need to use industry standards and structured documentation templates to record, receive, and transmit information electronically

9. Medical Billing Cycle

10. Claims Submission Post Service Post Submission Post Payment Gap 3
Coding and charge entry to by collecting and verifying information
Claim checking and error resolution
Check the insurers “payer sheet” or “companion guide”
Submit Claim
Post Submission
Check status daily
Resolve denials
Resubmit claim
Post Payment
Verify deposits
Reconcile co-insurance and co-payments
Bill patient for payments, deductible, and co-insurance
Gap 3
Coding and Claims Submission
Need to use industry standards to code and submit claims
Gap 4
Different Adjudicator
Need to understand medical necessity standards and contract requirements for each payer

11. Medical Billing Cycle

12. Medical claim process flow

13. Medical Claim process flow

14. Medical claim process flow

15. Medical Claims information
Regence manages ,000 medical claims daily
82-86% of medical claims auto-adjudicate
Primary reasons for encountering edits:
Payment generates (in general) within XXXX

16. Payment Gap 5 Payment Collection
Review and determine contract limitations and restrictions
Patient Follow up
Provide printed copies of Billing Policy to patients
Corrective actions for non-payments
Collection
Gap 5
Payment Collection
Need to track claims, review denials, and ensure payments
Need to collect payments from patients

17. Success to date Data from 1/1/16 – 7/27/16 2,090 claims submitted
1,184 claims for – 99215

18. Summary