Medical Billing Case Study

Accelerating cash collections at the point of service has never been more critical than it is today. Sophisticated accounting tools that enable providers to analyze patient utilization and outcomes help practice managers monitor payer performance and evaluate external contracts effectively. Growing financial pressure to strive toward more efficient claims flow through the revenue cycle means every provider must search for innovative tools to overcome the challenges.

Id. In order for providers to avoid costly claim denials, a risk management and compliance program should be in place and annual monitoring and auditing of internal controls needs to occur on a regular basis. This text will review the issues that medical providers face with coding and billing regulations, the consequences of improper billing and coding, and resolutions that will aid in the prevention of claims being denied.

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).

When I first read this discussion, it made me curious as to why it would be important to join a professional organization for Medical Billing and Coding. After reading about a few of them, I believe it is a pretty good idea. Joining a well known, professional association shows employers that you work to high ethical standards. It is also very hard to keep up with the quickly growing billing, coding, and compliance regulations. One of the organizations I read about joining is the MAB, Medical Association of Billers. This group provides members with the most updated information on Medicare and Tricare changes, coding & reimbursement trends, medical electronic claim submission, Healthcare Insurance Regulations, Medical ccounts Receivable strategies, managed care trends, and

The real problem as pertains to the reimbursement of managed care organizations is that these managed care has had an effect on slowing the rates of growth concerning the costs of hospitals and specialist physicians. For both the hospitals and practitioners, the sources of revenue have been shifted with over 20 percent of the charges being paid from the pocket, others coming from third parties who demand for complex accounting of the charges, lack a pre-authorization process and they can review in a retrospective manner and deny the reimbursement (Furrow et al., 2013). The

One question that faces every medical practice, hospital and urgent care center is whether to continue in-house billing or outsource their billing. Needless to say, there are pros and cons to each of these billing methods. However, there are several benefits to outsourced medical billing that are frequently overlooked.

Billing and Coding compliance strategies protect physicians from financial risk and potential loss of revenues. Physicians must document fully the service they provide and put in force a plan that prevent or reduce coding errors. According to, “The Journal of the National Medical Association,” there are 10 top billing concerns for physicians:

Medical coders, are always working side by side with medical billers and although many people confuse these professions as the same thing, medical coders and billers have different responsibilities individually. It’s a good idea to get your medical coding certification not only because most jobs now a days require some type of schooling, but its also a good idea because it shows the company that you are someone that could fit in just fine. Certifications also shows that you are proficient in your area and are committed to quality healthcare by disseminating quality information, it’s one of the first qualifications that employers look for when they review you as a potential candidate, and it’s an asset when you’re negotiating a salary. In addition, the majority of billing companies have contracts with their clients that obligate

2. Prioritize your revenue stream. Reduce denials. Avoid costly HIPPA violations. Give your medical billing staff resources and training that simplify your administrative routines. Choose AZZLY.

Year in ago, I went to school for medical billing. My teacher advised what can and can’t be done to a claims form. This is Billing 101. I trying to locate this information before. I think it’s something that you have to go to school for. Nevertheless, I will continue to look for something that you can reference to the provider. The rule is the claims has to either be all handwritten or all types. It can’t be both. You can’t us white out on a claim.

Some facilities outsource medical billing. ("Medical Billing," n.d.) Although this does cost the facility a certain percentage, the people handling the billing are already trained so there are no work hours lost to training the staff in the facility. This also almost completely stops the need for doctors and nurses to spend time on billing issues that come up. ("Medical Billing," n.d.) The hired medical billing specialists are also up to date in current standards, like HIPAA, so they are less likely to make errors in that regard. ("Medical Billing," n.d.) Then there are some facilities that choose to use in-house billing. The positive aspects of in-house billing are billing issues can be handled right away. ("Medical Billing," n.d.) Patients don't have to go through hoops to get their questions answered. The people who are in charge of the billing aspect in the office have direct contact with the doctor that provided the services. ("Medical Billing," n.d.) This eliminates the middle man and patients can possibly get their answers right away. Outsourcing may be easier for certain facilities, but in-house billing is more efficient for

The business goals of modern healthcare include the need to increase patient safety and satisfaction, to eliminate fraud, waste, and abuse, and to maintain employee satisfaction in order to control costs and increase profitability. However, in reviewing the history of healthcare reimbursement, this was not always the case and at a point in time existed where the cost of healthcare was escalating exponentially due to abuses in the way providers were allowed to utilize and bill for services. Due to this, the changes in how healthcare services are reimbursed changed dramatically over the past several decades with those changes designed to create savings for insurers and those entities paying health care premiums.

Resolve concerns, conflicts, and problems while ensuring that assistance is provided in a professional manner.

Medicare proposed revisions to payment policies in regards to the Physician Fee Schedule while focusing on primary care, chronic care management, mental health and diabetes. The recently proposed rule regarding physician fee schedules aims to improve payment, payment systems, and payment policies, as well as coordinates accountable care organizations’ quality measures with the current Medicare reimbursement rules, specifically, the Quality Payment Program and Medicare Access and CHIP Reauthorization Act, which rewards quality of care rather than the volume of care. CMS is updating payments to better reflect the changing healthcare community and value a service provides by increasing the amount of quality measures. Furthermore, in order to

Medical practices need billing collections procedures in place prior to opening the practice. These procedures make sure that service received by the patient is paid for, which allows the practice to continue to operate. First step is to have every patient sign the acknowledgement of the policy on billing, collections, insurance, copays and payment options the facility has in place prior to being enrolled in the system. According to Janet Colwell, Seven Steps to Consistently Collect Patient Payments Vol. 25 (23 Jan 2015), at every visit the patient and employee should verify the patient’s insurance is up to date and collect the copay before checking the patient in. Office management and administrative personnel collecting the payment should