Medical Billing - DME Software Biller Setup

In this installment of medical billing and the DME software setup, we're going to briefly cover what is involved with the setup that is specifically designated for the people who do the actual billing of claims. This is a very complex process that involves a number of items that all have to work together.

In order to bill an insurance carrier for a claim, there are a number of items that the biller needs access to. This includes the patient personal information, the item being billed, the carrier the bill is sent to and the method by which the bill will be sent. In order for this to happen, these things have to be setup in the system for the biller.

The first order of business is that the biller needs to have patient access. When the bill comes in, the patient number is usually on the first page of the bill. This number should have then been entered into the system along with the patient information. The biller will then have access to this information through what is called a patient lookup feature. These features usually have several fields by which the biller can lookup the patient, such as by last name, ID number, etc.

After the patient is found, the next thing the biller needs to know is what the item is being billed. These items all have to be setup in inventory, which is usually done by the inventory manager. Another lookup function is then provided to the biller for looking up inventory items. This is usually done by item name or sku number. Once the item is found in inventory, the item is then added to the billing sheet.

The next thing that the biller needs is the carrier that is going to be billed and the method by which the bill will be sent. The carrier is usually attached to the patient when the patient file is setup. But in some cases, the insurance carrier is not known at the time and the biller has to add it at the time of billing. For this, another lookup table is provided with all the insurance carriers that the system supports. These are usually updated on a regular basis. The way the biller knows which carrier to pull is by looking at the billing sheet that came in. The carrier is listed there.

The method by which the bill itself will be sent is usually determined by the billing agency itself. Not all agencies have electronic billing capabilities. In the cases where such capability doesn't exist, the default billing method will be via paper claims and the biller won't have to do anything. The claim will automatically go to the print que upon submission.

Naturally, the above process is greatly simplified, but for the most part, that is all that is involved with sending a bill for a medical claim. The truth is, if medical billing was this easy, there wouldn't be so many claims that get denied each day. The problem is that billers are not properly trained and the medical billing software itself can only do so much.

Michael Russell Your Independent guide to Medical Billing

Medical Billing Software – New Features to Look for in Your In Your Next System

New features can benefit you with a more efficient practice, lower costs, and increased cash flow.

Medical Billing Software and Physician’s Practice Management Systems are the best tools you can use to improve the financial well being of your practice. Using one can help you to gain full control over your finances, and grow your business. Cutting-edge medical billing technology can significantly reduce time and costs spent processing claims. Not only will you have a better grasp of the health of your practice, you can watch your receivables increase and your payables decrease.

In the past couple of years, new features have began to emerge to increase your operational efficiency. Spurred on by the HIPAA regulations mandating electronic file transfer standards such as X12, and the growth and maturing of the internet, new features are now available to help your business.

Recent advancements include:

1. instant access from anywhere, even away from the office
2. manage multiple offices and functions from one database
3. enhanced scanning - electronically file all claims; even those needing supporting documentation attached.
4. rules engines to identify errors before submitting the claim
5. increased security to comply with new HIPAA standards
6. electronic patient statements
7. electronic remittance advice

Stay Connected

With the maturing of the internet, new technology supporting the ASP (Application Service Providers) architecture allows access to your data including data entry from anywhere with a internet connection. This flexibility is a true benefit to multi-office practices and billing services. Multiple offices can now share the same database without the need for specialized networking or wide area networks. The cost savings in communication expenses alone can be enormous. Billing services can benefit by allowing limited access to their clients. This can instill a higher level of comfort for the client. This access can allow give a billing service a competitive advantage by providing value added services such as scheduling, super bill printing, and patient lookup.

Built in Efficiencies

Leveraging newer technology such as EOB and insurance card scanning, electronic patient statements, and electronic remittance can cut time spent on billing chores by up to 30%. This can allow more time for focus on patients and collections.

Reduced paper handling

Newer systems provide insurance payer rules so that users can immediately identify and correct claim errors that would delay payment of claims. Some systems will submit all your claims on your behalf including paper claims. Carriers can respond immediately so you get faster payouts, most within 14 days. Practice Management Systems can also reduce staff workload by outsourcing the print and mail functions of processing patient claims and statements.

When supporting documentation is needed in order for a claim to be paid, some systems can attach scanned letters of medical necessity, accident reports, referral authorizations, worker’s compensation documents, and most importantly EOBs. This eliminates the need to photocopy paperwork and perform chart pulls later if there are any questions on the claims.

Increased Security:

When using the internet, many users are concerned about security. A well established vendor addresses these concerns on multiple levels. Just like banking at an ATM, all data is encrypted during transmission and is protected by a user name and password. Furthermore, with most ASP vendors, all data and servers are backed up by expert IT staff at the data center. Many ASp vendors offer redundant HIPAA-compliant servers, with backups in different locations to ensure data recovery in case of disaster.

Conclusion

What is becoming standard in ASP-based medical billing software is subscription style pricing, and low upfront cost which cover implementation and professional fees.

If your business is looking to upgrade the medical billing software, examine the new features listed to see if they will offer you cost savings and increased efficiency. If so, insist on the new features in your next system. The cost savings can easily justify the upgrade.

Lori Anderson is an independent consultant with LAtech working with AntekHealthware on their DAQbilling Medical Billing Software and LabDAQ Laboratory Information System projects.

BCBS MI Heads Chiropractic Office Billing Software Precision Index For 2nd Month - BPI Drops 3.5%

Blue Cross Blue Shield Michigan heads Chiropractic Office Billing Software Precision Index (BPI) for the second month straight. Overall, May 2007 BPI dropped 3.5%, bringing the index from 14.6 down to 18.1, below the national average of 17.7%. May BPI replaced three BPI participants on the list of top ten performers. BPI guides chiropractic office managers and helps the development of both chiropractic billing software and billing performance standards.

BPI = 18.1 means that the average of ten top performing payers working with Billing Precision clients have 18.1% of Accounts Receivable beyond 120 days. BPI is a key billing performance characteristic, as it is a proxy of the claims that are never paid. Obviously, the lower is the index the better is billing performance. The table below also lists the top ten performing payers and their relative index as recorded in the Billing Precision's system.

• Billing Precision Index 18.1
• Blue Cross Blue Shield Michigan 3.2 (same)
• GHI 11.5
• Humana 11.8 (down from 7.9 in April)
• Blue Cross Blue Shield Colorado 12.3 (down from 6.8 in April)
• Medicaid Pennsylvania 15.1
• Assurant Health 15.4
• Blue Cross Blue Shield Illinois 16 (down from 11.1 in April)
• United Health Care 22.6 (down from 13.9 in April)
• Medicare New Jersey 20 (down from 16.4 in April)
• Cigna 24.1 (down from 15 in April)

May BPI dropped three participants since April:

• Blue Cross Blue Shield Texas 20
• Great West 22
• Aetna 22.1

No payer improved its index since April.

Six participants lowered their indexes with respect to April BPI:

• Humana 11.8 (down from 7.9 in April)
• Blue Cross Blue Shield Colorado 12.3 (down from 6.8 in April)
• Blue Cross Blue Shield Illinois 16 (down from 11.1 in April)
• United Health Care 22.6 (down from 13.9 in April)
• Medicare New Jersey 20 (down from 16.4 in April)
• Cigna 24.1 (down from 15 in April)

May BPI added three new participants since April:

• GHI 11.5
• Medicaid Pennsylvania 15.1
• Assurant Health 15.4

Coverage

BPI is rule-based, i.e., payer participation in the index is defined by dynamically rules at the time of computation and not by a static listing of specific payers. Therefore, any specific payer may start or discontinue participation in the index, dependent on satisfaction of rule's conditions.

Current selection of payers for participation in the BPI is based on fifty top-volume providers across all United States that have received Billing Precision services for more than six months and have more than two hundred claims in their current Accounts Receivable.

Update Cycle

BillingPrecision.com updates BPI on a monthly basis.

Volume Weighting

BPI is volume weighted, which is important to accommodate future growth of provided information, index combinations, and sensitivity across multiple indices.

Information Provided

BPI computes the percent of Accounts Receivable beyond 120 days. Note that national average across all medical specialties of percent of accounts receivable beyond 120 days is 17.7%.

Summary

Chiropractic Office Billing Software Performance Index helps the development of both chiropractic office billing software and billing performance standards. Chiropractic office managers can use the index to benchmark their billing performance and guide its improvement over time. Rule-based index definition allows for automated inclusion and exclusion of payers in the index based on payer attributes, such as numbers of processed claims, accounts receivable distribution, certain mix of CPT codes, or patient demographics.

Yuval Lirov, PhD, author of "Practicing Profitability - Network Effect for Revenue Cycle Control in Healthcare Clinic and Chiropractic Office: Scheduling, SOAP Notes, Care Plans, Coding, Billing, Collections, and Audit Risk" (Affinity Billing) and "Mission Critical Systems Management" (Prentice Hall), inventor of patents in Artificial Intelligence and Computer Security, and CEO of Vericle.net - Distributed Billing and Practice Management Technologies. Yuval invites you to register to the next webinar on audit risk at BillingPrecision.com

Electronic Medical Billing OLAP Software for Lost Revenue Discovery

Average medical practice may lose as much as 11% of its revenue due to underpayments. But underpayment recovery potential averages only 5% of revenue and involves costly appeal process. To avoid unrecoverable losses, some providers discontinue servicing patients insured by the worst performing payers. Unfortunately, such a drastic loss reduction measure may boomerang and increase losses depending on complexity of referral relationships. This article outlines limitations of traditional database queries used to identify payer candidates for contract termination and demonstrates alternative decision choices with superior performance in terms of revenue and risk management, facilitated with On Line Analytical Processing (OLAP) technology.

First Order SQL Queries for Accounts Receivable Analysis

Traditional accounts receivable analysis includes identification of payers that systematically underpay and refuse denial appeals. Such analysis is based on simple queries, designed to identify the best CPT code or the worst payer in absolute terms:

• Comparison of revenue for various CPT codes for a given time-period
• Comparison of underpayments for various payers for a given time-period
• Comparison of denials for various payers for a given time-period

 

A single key database indexing is a standard measure to improve time performance of such queries. It builds an ordered relationship within the data elements based on the value of the selected metric. But single key indexing precludes implementation of more complex queries like "who is the payer that underpays the most for the best CPT code," or "who is the worst referring physician for my worst payer?" and require complex SQL programming skills because of the need to store and process intermediate results. Therefore, ranking the data elements along a single attribute, forces a limited choice for management decision:

• Ignore the problem,
• Renegotiate the contract with the payer, or
• Stop serving patients insured by the worst payer.

 

But to find more subtle solutions the office manager requires the ability to aggregate and drill into data and formulate queries in real time, in response to observed results to the previous queries. Specifically, a low frequency under performing payer with a high degree of underpayment may not be as detrimental to the office as a high frequency under performing payer with a low degree of underpayment. Contract termination with a wrong payer may accomplish the opposite result to practice goals in terms of revenue maximization and workload reduction. Additionally, a decision to stop serving patients insured by any one payer may cause reduction of referral volume of other patients across all payers for a particular referring physician.

Combinatorial (Second Order SQL) Queries for Accounts Receivable Analysis

Fortunately, modern database query technology can address both limitations by enabling "second order SQL" queries, which allow data manipulation based on multiple criteria and using functions of combinations of such criteria.

In our case, second-degree SQL queries allow finding the worst payer for best revenue generating code. Such a discriminating approach allows focusing on higher priority items first, resulting in more effective management. In general, the manager performs a custom comparison of payers according to the following four-step sequence:

 

• Select metrics (e.g., % paid, % accounts receivable beyond 120 days, % denials)
• Select dimensions (providers, payers, CPT codes, ICD-9 codes, referring physicians)
• Partition
• Aggregate, drill-down, pivot

 

Worst Payer Query

To find a payer with highest amount of underpayments for the most-frequent CPT code, a second order SQL query can be written along the following lines:

For a given time-interval,

Select payers

Where sum of underpayments over

(all CPT codes Where Revenue > Revenue Threshold) > Underpayment Threshold

Worst Referring Physician Query

To avoid the risk of losing referrals from better-performing payers, the manager may consider severing referral relationship with some referring physicians instead of payers. In such a case, distribution of patients across various payers plays an important role for each referring physician. A single combinatorial query may fetch the Worst Referring Physician as follows:

For a given time-interval,

Select referring physicians Where Revenue for the Worst Payer > Threshold

Summary

Underpayment management involves all phases of claims processing and requires powerful Vericle-like computing platforms for exhaustive comparisons of payments versus allowed amounts and subsequent appeal management. OLAP allows better analysis of accounts receivable and more effective management because of the ability to handle queries with functions of multiple attributes and dimensions. Note that in the absence of native OLAP mechanism, effective Vericle-like billing platforms allow similarly powerful analysis by introducing intermediary steps. Such steps may add insight to analysis and improve decision quality.

Yuval Lirov, PhD, author of "Practicing Profitability - Network Effect for Revenue Cycle Control in Healthcare Clinic and Chiropractic Office: Scheduling, SOAP Care Plans, Coding, Billing, Collections, and Audit Risk" (Affinity Billing) and "Mission Critical Systems Management" (Prentice Hall), inventor of patents in Artificial Intelligence and Computer Security, and CEO of Vericle.net - Distributed Billing and Practice Management Technologies. Yuval invites you to register to the next webinar on audit risk at BillingPrecision.com