Medical Billing Reflection

Double billing is when a patient is billed for the same service more than once. Double billing can occur when there is a product name change and also if there is an error involving the product's software. There are different reasons why a medical claim could be denied. Here are some of the reasons why:

As viewed by many HIM professionals Computer-assisted coding is a valuable tool for enhancing the effectiveness of coding and billing. CAC software scans medical documentation in the electronic health record (EHRs) using a natural language processing (NLP) engine, identifying key terminology and proposing codes for that specific treatment or service. Human coder then revised these codes. CAC can also investigate the background of key words to conclude whether they need coding.

6. Why did the Centers for Medicare and Medicaid Services (CMS) implement the National Correct Coding Initiative in 1996?

The most important element in becoming a Medical Billing and Coding Specialist is the training and certification need to enter the field and for advancement. You will need a program that provides an understanding of anatomy, physiology and medical terminology. This program should also navigate the three topics: ICD, CPT and HCPCS. These codes help you document the conditions of a patient and describe the procedure performed on the patient. When you have completed your training there are several certifications you can test for. The American Health Information Management Association (AHIMA) offer certification for the Certified Coding Associate (CCA). You will need AHIMA membership and an exam fee ($199- $299), a high school diploma or

"Medical coding professionals provide a key step in the medical billing process. Every time a patient receives professional health care in a physician’s office, hospital outpatient facility or ambulatory surgical center (ASC), the provider must document the services provided. The medical coder will abstract the information from the documentation, assign the appropriate codes, and create a claim to be paid, whether by a commercial payer, the patient, or CMS." (Aapccom, 2015) It is very important that billing coders have a full understanding of how to properly use medical codes to prevent denial of claims submitted.

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).”

Internal and outside auditors have a heavy role and responsibility in performing audits, preventing major accounting errors, and following (GAAP) guidelines. Several duties comprise the role of internal and outside auditor to follow specific protocol and ensure ethical standards are priority. The National Health Care Billing Audit Guidelines are relevant to address as well as why audit failures happen. Finally, how internal vary from external audit and why audits are overall important to health care organizations. It’s vital for health care organizations to maintain all necessary standards to conduct proper audits and uphold ethical standards for the financial health of the organization.

Amy holds a bachelors degree in accounting and has worked in the medical billing field for over twenty-five (25) years. Her exhaustive knowledge of reimbursement coupled with her attention to detail has been essential in servicing new and existing clients. Her leadership and knowledge, has in every aspect of the revenue cycle

When working as a medical office administrator you will need to know how to complete the different procedures dealing with physician billing and reimbursement. Reimbursements involves more than what you just get paid, it’s a long and often convoluted process that start when you patients first contacts your office. In order to get the correct reimbursement it is important that you know the basics about reimbursements which includes the correct coding. The way to understand the aspects of the business is to know the basic of Medicare. Physician reimbursement is a three step process. The first step of the process would be having the appropriate coding number of the service provided by utilizing the current procedural terminology which is commonly

Some estimate that the federal government loses 30 percent of every dollar it spends on medical claims, due to medical billing mistakes and fraud. With so many loopholes and regulations surrounding Medicare, it is impossible for one person to know every nuance. However, constant diligence and ethical practices are a cornerstone of catching and preventing medical billing mistakes.

Most claims today are submitted through an electronic format directly or indirectly through a “clearinghouse” where claims are grouped and sent to the payer. Two primary payment grouping algorithms are DRG’s and APCs, both are used by Medicare for hospital payment and many commercial payers. Providers and payers use claims editing software to detect possible errors in claim submission to assure maximum payment for medical services and to shorten an amount of time from claim submission to payment. CMS has developed the National Correct Coding Initiative (NCCI) to promote national correcting coding methodologies and to control improper coding leading to inappropriate payment (Cleverley 26). CMS also has designated edit checks called the outpatient code edits (OCE). The OCE uses claim-level and line item-level information in the editing process. Each category in the OCE has six dispositions which help to ensure all Fiscal Intermediary/Medicare Administrative Contractor (FI/MACs). The four claim-level is rejection, denial, return to provider, and suspension; and the two-line item-level is rejection and

The process for medical billing involves a health care provider submitting, and following up on claims with health insurance companies in order to receive payment for services rendered; such as treatments and investigations. Once the procedure and diagnosis codes are determined, the medical biller will transmit the claim to the insurance company. Most physicians have medical directors that review claims for patient eligibility. Physician reimbursement and the coding to support it are critically important to the sustained health of any physicians practice. Under the contract provisions the physicians are responsible for rendering the services to the patients. In the billing process physicians need to know how services are rendered.

When I was younger I wanted to be a nurse, as I grew up my career choices changed based on different situations. I was a nursing major my first years of college. After witnessing different situations in life and job shadowing a nurse, I decided I wanted to be the person the patient talked to and confided in. I change my major to psychology in hopes of becoming a counselor. I received my bachelors in psychology then realized that it was not possible to become a counselor without a master's degree. So now I am in the process of finding another career that I would love. Medical billing and coding allows me to stay within the health field and gives me experience in a medical setting. Medical billing and coding is a well-paying entry level job.

The billing for services not rendered for are often done as a way of billing Medicare for things or services, that basically never occurred. This can involve forging the signature of those enrolled in Medicare or Medicaid, and the use of bribes or as Healthcare calls it, kickbacks to corrupt healthcare professionals. Upcoding of services is the act of billing Medicare programs for services that are more costly than the actual procedure that was done. Upcoding of items is also very similar to upcoding of services, but it involves the use of medical equipment. For example, billing Medicare for a highly sophisticated and expensive wheelchair, while only giving the patient a manual wheelchair is upcoding of items. Duplicating claims occur when a provider does not submit exactly the same bill, but alters small things such as the date in order to charge Medicare twice for the same service rendered. Therefore rather than a single claim being filed twice, the same service is billed two times in an attempt to receive payments from the government twice. Unbundling involves bills for particular services are submitted as fragmentary, which appear to be staggered out over time. Although, these services would normally cost less when bundled together, but by manipulating the claim, a higher charge is billed to Medicare resulting in a higher pay out to the party committing the healthcare fraud. Excessive services occur when Medicare is billed for something greater than what the level of

A great opportunity to discover whether or not you actually want to do the job you have been dreaming about your whole life is to explore that career field. I was granted the opportunity to job shadow a medical records technician, also known as a medical biller. I haven’t always wanted to be a medical biller, but I have had an interested in the medical field. The chance to shadow Mrs. Latoya West at Advantage Medical Billing allowed me to see that the medical field was something that I would like to continue to pursue, but not as a medical biller. During my time, I did discover a few interesting things.