Coder Interview

When people think about jobs in the health care field, it can be easy to assume that most jobs involve direct, hands-on patient care. What many people don’t realize is that administrative jobs are equally vital to ensuring quality health care services. Medical billing and coding is an important piece in the administrative puzzle that makes up the vast health industry. As with most administrative jobs, medical coding and billing professionals need to have excellent attention to detail, as one wrong code or inaccurate statement can have an extremely negative

Once the patient comes through the door payment for services should be top of mind. All copayments and deductibles collected and any other non-covered expenses billable to the patient. The correct information is gathered and if all is handled initially properly within in the cycle the claim can go the workflow and payment received with minimum effort by human hands.

Now a statute, the physician/hospital pay for quality, not quantity, public law number: 114-10 signed April 16, 2015 also referenced as H.R.2 —1st Session of 114th Congress (2015-2016), sometimes called the “Permanent Doc Fix” 04/14/2015 : Passed Senate; 03/26/2015 : Passed House (Medicare Access and CHIP Reauthorization Act of 2015, 2015), which defines the payment and reimbursement reform to doctors treating patients with Medicare. This extensive reform includes the CHIP program insuring children and those families that don’t qualify for Medicare but are unable to afford private insurance and is funded by the federal government and individual states.

Decrease in funding is another economic challenge in health care. The amount of finances coming from various sources not just the

My career that I am researching for my junior project is Medical Coding and Billing. Medical Coding and Billing are two different jobs. Medical Coding is when a patient has any medical procedure or exam such as going to the doctor for the stomach virus or even going to the hospital for a broken bone. They work with the insurance companies by putting a specific number into the computer. There’s CPT Codes which stands for Current Procedural Terminology which is “ Codes to better understand the services their doctor provided, to double check their bills or negotiate lower pricing for their healthcare services. (About Health, 2014).”

The reimbursement method used at St. Anthony’s hospital is quite distinct depending on the party doing the payments. Payments are received from Medicare, Medicaid, private insurers and also directly from patients. The party responsible for Medicare payment is the Federal government and it offers payment mainly for the elderly. With the Medicare payment, hospitals receive a flat fee depending on the case. According to Gee (2006), most hospital revenue has declined because of the revised payment set by the Diagnosis-Related Groupings. The fee for most cases varies according to the Diagnosis-Related Group (DRG) it can be classified under. For example, Medicare pays only a fixed amount for an elderly patient suffering from pneumonia regardless

Another reason for the rising cost of healthcare is the cost of physician care, according to the American Hospital Association “the cost of physician care, both to insurance and patients, has risen 1.3% during the past year.” Because of this increase doctors are put in a corner, they are already locked into an agreement with the insurance companies and do not have much ‘wiggle’ room to negotiate fees and rates. So because of this the patients and consumers are forced to pay a much larger sum. Since there are higher costs and the insurers will not cover them, they are distributes to the customers through higher deductibles, co-insurance, and

Data then flows into two functions: (1) the medical documentation, which becomes the basis for clinical decision making and goes into the medical record; and (2) the charge capture or entry, where the manual “charge slips” or automated direct order entry are priced in accordance with the price list referred to as Charge Master, also called Charge Description Master (CDM). Thereafter, data from both Medical Record and Charge master flow right into the billing system. Then, claims preparation follows by filling up of either of the two types of forms: (1) UB-04, which is used by hospitals for inpatient and outpatient service claims, or (2) CMS-1500, which is used by Physicians for professional claims. These forms are then carefully reviewed in the claims editing process to ensure there is enough information to warrant payment by the payer, and logical standards are complete and well documented. (Claims Editing is not conducted by all health care facilities, but is a critical effort to secure accurate and timely payment by payers). Finally, the claims are submitted to the payers.

Besides, the financial incentives for hospitals and physicians that belong to ACOs, Jaffery & Golden 2013, asked and then answered the question “why would providers join this program? One reason is to prepare for the future”. Fee-for-service reimbursement, which has been how hospitals get paid for their services rely solely on the volume of patient seen without taking into consideration the quality of care provided. Payers today, such as government, commercial insurers, employers, and individual consumers are now requesting on value -based-payment, which consist of delivering the highest level of care at a lower cost. The volume based system even though the traditional way of how payments are made is not a viable long-term option (Jaffery and Golden, 2013, p.98).

Another solution to making a good profit for a healthcare practice is to perform services that provide a good reimbursement rate. For a new for-profit health care organization CCHC advised that the facility seek out the average Medicare, Medicaid, and private reimbursement schedules. When reviewing these schedules a provider can determine where the profit of services lies. From here the provider can perform additional research by conversing with its peers to see what kind of profit ratio they are running in their facility, as well as what particular services provide the best reimbursement rates. This would be a good start for the new practice. As services are being provided, and payments are being sent the provider should take a hard look at the reimbursements being given for services rendered. If it appears that a particular service is bringing in little or no reimbursement, the practice may need to decide whether or not to continue the service.

Current healthcare reimbursement system bogged down with problematic healthcare rules and governing reimbursement regulation/policy divided by the ever changing economic growth on a day-to-day basis. American healthcare insurance provides variety of healthcare reimbursement program, and each entity is contracted with individual practices or organized health systems. The price of each services that occurs within a health care system allowing payer and insurers’ to adjust services cost that occur outside that system.

A key piece of information in putting together the healthcare financial puzzle is to look at how healthcare dollars are spent. Hospital care is the single highest spending category at 31% with providers and clinical services at 20%. Not surprisingly when cuts are proposed, these big ticket items are looked at first.

Understanding the classification of healthcare services in terms of acute and long term care enable us to plan for services, to describe institutions, and to allocate funding and reimbursement. In the United States, healthcare services provided by health care providers (such as doctors and hospitals) are paid for by the following including, private insurance, Government insurance programs, people themselves (personal, out-of-pocket funds). Additionally, the government directly provides some health care in government hospitals and clinics staffed by government employees. Examples are the Veteran’s Health Administration and the Indian Health Service.

As early as the 1990’s, outpatient care only made up for 10 to 15% of a hospital’s total profits, compared to inpatient care. Since the start of the twenty-first century, this figure has increased to approximately 60%. This shift in healthcare has been occurring in different medical organizations such as university medical centers, local hospitals, for-profit chains, and not-for-profit suppliers. The increase in outpatient services compared to inpatient has been showing no indication of slowing down. The main reason for the development in outpatient care is because of all the medical advancements in techniques and technology that allow for patients to be treated less invasively. Health care organizations are now being compensated in a

With the ever escalating costs of health care, all providers are more aggressively, pursuing cost containment measures. Nurses are generally the