Thursday, 10 October 2013

Medical Billing Workflow

     Note : In Medical Billing, people use different words for the same thing; Here are those most commonly used;

  • Doctor is also referred as Physician or Provider
  • Doctor Clinic is also referred as Doctor Office, or Physician Office or Provider Practice or Provider Facility; So facility or practice or clinic or office refers to the place where the patient meet the doctor;
  • Insurance is also referred as Payer or carrier
    Use case 1 : In House Billing 
  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
  4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code; ( ICD means International Statistical Classifications of Diseases. ICD codes are alphanumeric designations given to every diagnosis, description of symptoms and cause of death attributed to human beings.Some example for ICD Codes)
  5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; (CPT means Current Procedural Terminology codes, are procedural codes published by the American Medical Association, describing what services the provider actually performed on the patient. Some example for CPT Codes)
  6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;
  7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
  8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
  9. Once the Claim is prepared and send to the Insurance company for payment; 
  10. Insurance company pays the doctor office;

     Use case 2 : In House Billing with Two Insurance

    Many patients only have one insurance plan but it is  possible for a patient to have two or three medical insurance policies. The first insurance billed would be
    the primary insurance. The next one billed would be the secondary, and the last would be the tertiary.

    First the primary carrier must be billed first and then balance is billed to the second insurance carrier with the primary insurance payment  information.
    If there is a third or tertiary insurance, it is billed last with payment information from the first two.

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc) and insurance information; 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
  9. Primary Insurance company pays the doctor office; 
  10. Billing Department notified that claim has still some balance after Primary Insurance is paid. Since the Patient has another insurance (secondary), so now the billing department send the claim to the patient secondary insurance to collect the remaining balance.
  11. Secondary Insurance Process the claim and pay the remaining amount to doctor office

     Use case 3 : Self Pay

Patients who are not covered by health insurance(does not have any insurance) are considered “self pay” patients. They or the responsible party they designate are totally responsible for their own bill. Not everyone is covered by health insurance. The ones that aren’t covered are considered self pay and just like in the old days, these people must pay for their visits themselves.

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and since there is no insurance for the patient, so patient statement is generated and send to the patient for payment;  
  9. Patient Receives the Statement and Payment is made to the doctor office.
Use case 4 : Patient Responsibility

Some insurance policies pay a percentage rather than a set amount. Anywhere from 50% to 80% is very common for some insurance policies. Once they pay their  portion, there may be a patient responsibility remaining. This amount is generally billed to the patient after the insurance payment is made.
  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment. 
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc). 
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease); 
  4. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code; 
  5. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient; 
  6. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company; 
  7. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting; 
  8. Once the Claim is prepared and send to the Primary Insurance company for payment;  
  9. Primary Insurance company pays only 80 % of the Bill to the doctor office; 
  10. Since there is no other insurance for the patient and claim balance is still 20 %, so now the billing department change the responsibility of the balance to patient and patient statement is generated.
  11. Billing Department send the Statement to the Patient.
  12. Patient Receives the Statement and Payment is made to the doctor office.

     Use case 5 : Clearing House Work flow

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.) and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
  4. Each Disease represents by a Code. That code is called ICD. It is also called Dx Codes or Problems or ICD Codes or Diagnosis Codes; So for each patient visit, doctor choose the correct ICD Code;

  5. Each treatment represent a code and that code is called CPT. It is also called Procedure Codes; So for each patient visit, doctor choose the correct CPT Code;

  6. Once all the process are over, now patient leaves the doctor room. Now the doctor office to get paid for the service provided to the the patient;

  7. Since the patient has health insurance, so patient leaves(checked out) the clinic and ask the clinic to get money from the insurance company;
  8. Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge entry or Charge Posting;
  9. Once the Claim is prepared and send to the Insurance company for payment; 

  10. Billing Department using the Practice Management System (PMS), send the claim via EDI File. The EDI Transaction used to create the claim in the Electronic format is EDI 837
    Refer the Following Link to understand more on EDI 837
    What is an EDI ?
    EDI 837 Health Care Claim
  11. Once the 837 EDI File is created, then it will be send to the Clearing House.
  12. Clearing House will validate the EDI File and send to the particular insurance company.
  13. Insurance Company Process the Claim and prepare the Check (Cheque) and Statement(This statement is called Explanation of Benefits OR Remittance Advisory (EOB)          
    Refer the following Link for EOB
    EOB - An explanation of benefits 
  14. Insurance company also generates the EDI 835 File using their System. EDI 835 is electronic version of EOB.
    The Electronic Remittance Advice (ERA), or 835, is the electronic transaction which provides claim payment information in the HIPAA mandated ACSX12 005010X221A1   Format. These files are used by practices, facilities, and billing companies to Auto Posting payments into their systems.
    Refer the following link for Sample

    EDI 835 Health Care Claim Payment/Advice:
  15. Once the Check, Statement (EOB) and ERA File are ready, then insurance company first send the ERA File and EOB to the clearing house.Second , insurance company  will send the Check and copy of the EOB to the billing provider address . Third for each patient in the statement, the copy of the EOB will be emailed.
  16. Now the Billing Team download the EOB and ERA from the clearing house. If the PMS system has Auto Posting Using ERA File, then they will download the EDI File and do auto posting. If there is no auto posting Module, then they will download the EOB PDF and apply posting manually.Remember, some time, ERA/EOB file will be reach the clearing house, even before the insurance company send the payment check to the doctor.

 

     Use case 6 : Lab Billing

  1. Patient Calls / Walks to the Physician(or Doctor or Provider) office to fix an Appointment.
  2. On the Appointment day, patient checked In to the office and give all the demographics information(last name, first name, DOB, address,etc.)    and insurance information;
  3. Doctor check the Patient Previous medical record and does the treatment to the patient for the current problem(or Disease);
    Doctor Wants to check Blood test of the patient, so he request the patient leave the blood sample in the reception.
     
    The above steps are usually handled in EMR Software running inside the doctor office.
    Search Google : EMR lab request

  4. Patient leave the blood sample in the container provided at the reception desk. If the EMR running inside the doctor office are integrated  with Lab LIS, then via HL7, the doctor office place the order using the EMR software. if not integrated, the doctor office staff fill up  lab requisition order form manually and send to the Lab via fax or email. Some LIS System having Doctor Portal where the doctor office staff can login and place the order in the portal.

    Search Google : sample lab requisition form

  5. Every day Lab Transportation department visits the doctor office and pick the patient samples and shifted to Lab on same day.

    Search Google : Lab sample transportation

  6. Once the Lab receives the Order form, it will be assigned to the lab technician to do the blood test. Test technician checks the blood sample  and he prepares the Test result which contains various components with low/high value indication.

    Step (3) 4 are usually handled  in Lab LIS Software running inside the Lab .

  7. Now the Lab has get to paid for their work. Since the patient has insurance, so the Lab team forwards all those information with final result  to billing department to generate the claim and send to insurance company. If the LIS is integrated with Billing software, then information  are send via HL7 to the Billing software. If not, lab team manually pass the information by creating as PDF and forward that to the Billing  department.

  8. Now billing billing department receives the final result with all patient demographics information and insurance information.
    Now the Billing department of the Clinic prepare the Bill(Claim) by entering all the necessary information. This process is called Charge  entry or Charge Posting; 

  9. Once the Claim is prepared and send to the Primary Insurance company for payment;
  10. Primary Insurance company process the claim and send the payment to the Lab;

    Step 6,7,8,9 are usually handled in Practice Management Software or Medical Billing running inside the Lab or Billing company where they outsourced their work.

So three systems are involved (EMR, LIS and PMS) to do Lab Billing.  If the software supports HL7 Protocol, then the information can be easily passed between the system without manual data entry work.

HL7 is the standard to which healthcare application vendors adhere when developing application interfaces to exchange patient data. The HL7 standard defines a method of moving clinical data between independent medical applications in near real time

 


Example  Conversation during Patient check In process.


Jake : Calls the MyfirstHealth Landline Number.

Linda : Hello, This is Linda from MyfirstHealth Clinic . How can i help you ?

Jake : Hi Linda, My Name is Jake,I would like to meet Dr John today evening after 5 PM.

Can you please confirm doctor appointment is available ?

Linda : Sure, Let me check my records. Yes doctor is available after 5 PM. Do you like book the appointment ?

Jake : Yes Can you please make it at 5.30 PM ?

Linda : Sure. May i know you are coming first time to this clinic or you have already came ?

Jake : This is the first Time;

Linda : Good. May Know your last name, first Name and DOB to make a note in my records.

Jake : My Last Name is Jake; My First Name is : mike; and my DOB is xx/xx/xxxx.

Linda : Ok Got It. Please come 15 min before the appointment, so that we can get all your insurance information,etc.

Jake : Ok Sure.

That's all


At 5.15, Jake arrives the clinic and meet the reception the Linda.
Jake : I am jake, I've appointment with the Doctor John at 5.30 PM

Linda : Welcome Jake; Let me pull your records from the desk.

Jake : Sure

Linda : Jake. Do you have insurance to cover your illness ?

Jake : Yes. I've Insurance.

Linda : Please give your insurance information, so that after the visit, we need to send the bill to the insurance company

Jake : I am working in a company called xxx , My employer covers my health insurance. Do you want to give that insurance
information ?

Linda : Yes Please.

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Wait a minute. Apart from my employer insurance, i also have taken family coverage from another insurance.
Do you want to give that information also ?

Linda : Yes Please

Jake : Here you go. Insurance Name :xxxx. Policy No :xxxx, etc.

Jake : Hey apart from employer and my family, I've also have another insurance under my own name ?
Do you want to give that information also ?

Linda : Yes Please
Here what Linda does in the records She marked Employer Insurance as Primary, and Family Insurance as Secondary and Its own Insurance as third.

Jake : Hey i've question. Why you are collecting all my three insurance ?
Linda : Well, Once your visit is over, we will send the bill to your employer information company first and once we receive the payment, we will check whether still the bill has some more balance. If there is balance, then we will send the bill again to your family insurance company and so on.

Jake : Oh it is great process. I got it.

Jake : But I've stupid question if you don't mind.

Linda : Please go ahead

Jake : If you send the bill to my family insurance again, then you will get paid twice :). So you will get two payment
for one service ?

Linda : No it is not like that way it works. Once we receive the payment from your first insurance, if there is  balance, then we will send the bill to your second insurance along with the payment information of your first insurance. So your second insurance will check what is the first insurance paid and then they will pay only the remaining balance.

Jake : Wow that is great.

Jake : What happens if still there is balance in the bill, after my second insurance send the payment.

Linda : Well, since you have third insurance, we will send the bill again to your third insurance with the paid information from your first and second, so now your third insurance will know what has been paid by first and second insurance, then they will pay the remaining balance.

Jake : Wow that is really great process. You lot of work to do :)

Linda : Yes we always at your service sir.

Jake : But still I've another question if you don't mind ?
Linda : No problem. Go ahead

Jake : What happens if my bill still have balance after you paid from my third insurance ?
Linda : Well, Finally we will prepare the statement on your visit which will contains information about the service given and how much we got paid from all your insurance and at the bottom you can see how much you need to pay the balance. The statement will be mailed to you. Once you receive the statement, you can send the payment via check, or any other way.
Jake : Got It. I am done with my questions. Now what i want to do ?
Linda : Well. Please wait for 5 min. Our Nurse or Provider assistant will call you to do preliminary process.
Jake : Thank You.