For careers in medical billing, here’s a continuation of most commonly asked questions for other subjects that don’t fit in the jobs, training, software, and business categories.
What is medical billing fraud?
Medical billing fraud can take on many forms. The most common are upcoding, down coding, and submitting claims for service not really provided or not medically necessary. The Office of Inspector General in the U.S. Department of Health and Human Services is the government agency that focuses on medical billing fraud.
What is medical billing codes Unbundling?
Unbundling is a form of medical billing fraud. Medicare, Medicaid, and commercial insurers have special reimbursement rates for treatment procedures usually performed together. When unbundling occurs, the providers submits and bills the tests or procedures separately with the intent to increase the payments. This is because the payment when submitted separately is greater than the payment when the procedures are performed together.
It’s also sometimes referred to as fragmentation.
What are the laws regarding access to patient medical records that you should know for careers in medical billing?
Only the patient and health care provider directly involved in the patients care have the right to view the records. However the patient may give consent for any person or entity to evaluate the record. Billing services are typically covered under business associate agreements with the provider.
In general, most medical records laws allow access to the patients medical records when they are physically not able grant consent.
Here's more discussion on medical records laws that may be helpful.
Why outsource to a healthcare billing service?
The benefits of outsourcing a providers medical billing is it relieves the staff of these tasks. In some practices the billing is treated as a burdensome administrative task. As such it doesn’t receive the attention required which results in many unpaid claims and outstanding patient balances. There’s also can be a high amount of turn over in this position.
A medical billing service concentrates only on the billing. Because its all they do - they are very good at it and know all the pitfalls of the reimbursement process.
In many cases outsourcing the billing to a capable billing service will more than pay for itself in the additional revenue generated.
What is Upcoding and Downcoding?
Upcoding is when a diagnosis is made that results in a higher reimbursement than is really medically necessary. Downcoding is the exact opposite - it the assignment of a lesser diagnosis intended to show patient improvement.
How do you determine fees for physicians billing services?
It really depends on the competition, the specialty, size of practice, and level of service offered. I’ve seen it range from 4% for basic claim submittals to 10% for full service. More typical is the 6% to 9% range. You have to make sure you cover your costs and still make decent pay for your services.
Here’s more information on setting your fees
How do you handle patient past due medical billing collections?
Depending on the services negotiated with your provider you would typically send two or three notices when past due - unless the patient has worked out payment arrangements. That may also be followed up with a phone call reminder. After that the past due account are typically turned over to collections. The provider makes the ultimate call on collections though.
Can we just print out a 1500 health insurance claim form instead of using the pink forms?
Probably the most commonly used medical billing form is the CMS-1500. But you can’t get it for free. In other words you can’t find a pdf version of the form on the Internet, print it out, and use it to submit paper claims to an insurance company or Medicare/Medicaid. You have to use the pink colored official form dated 08-05 - the pink color is important. That's because almost all insurance payers scan the form when they receive it and convert it into an electronic claim. That right - even when you send a paper claim into an insurance payer - they convert it to an electronic claim. The reason for the pink form is when the form is scanned, only characters in black ink are scanned. The red ink is basically transparent to the scanner.
Here’s more info on the 1500 health insurance claim form.
The Frequently Asked Questions for other medical billing categories are on individual pages as follows - just click on the link to go to the section.
If you have a question about careers in medical billing that are not answered here, feel free to ask here.
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