Preventing Medical Billing Fraud

According to experts in medical billing, the government loses thirty cents per dollar earned due to fraudulent practices that happen in the medical community. Medicare fraud is a felony and suppliers, recruiters, providers, beneficiaries and companies of medical services can commit it. Types of medical billing fraud include writing bills for services that have not been provided, billing services that are not covered as services that are covered and unbundling of services among other activities.

There are many ways in which an office can prevent billing fraud. One of these methods is through screening employees. Any employee applying for a position as a medical biller should pass through screening, which involves performing a background check and asking to see the candidate's billing certificates.

The other way to prevent medical billing fraud is to set up a compliance program that will allow you to prevent fraud.

Such a program should be overseen by personnel granted the responsibility to recommend consequences once he or she detects fraud. The reason of the program should be communicated to all employees, letting them know of the procedures and standards involved in it. The other thing that an employer can do to prevent medical billing fraud using the compliance program is to include a method designed to report abuses without fearing penalty and retribution if an employee breeches the standards of the program.

The other way in which billing fraud can be prevented is through compliance with the Health Insurance Portability and Accountability Act (HIPPA), which is a federal legislation that is intended to offer protection to a patient's personal health information and privacy.

This legislation ensures that a patient's protected health information, which includes any information that can identify a patient, is kept secure. This information includes patient names, medical records, social security numbers and addresses.

The precautions that an office can follow in order to ensure that the information remains secure includes ensuring that computers are password protected so that others cannot view patient information, ensuring that fax machines are placed in areas where the public cannot access them and encrypting emails that contain patient information. In addition to this, the people having access to a medical billing office should sign a confidentiality statement.

These practices should apply also to a third party medical billing service and this can be done through the use of business associate agreements and contract clauses.

Medical Billing Books - Important Considerations Before Buying

If you search the Internet for Medical Billing books, the choice can be overwhelming and it's hard to separate the pretenders from the experts.

Not only are conventional books available from traditional sources, but ebooks are becoming even more popular as you can download your book in electronic form instantly. These are typically in PDF format but can also be in standard word processing format.

The Author

Probably the most important consideration when purchasing a billing book online is the source. Before you rush and click on the "Add To Cart" or "Buy It Now" button, examine the credentials of the author. Any reputable author should share their credentials and accomplishments.

Whats their background? Do they have extensive experience in the profession or are they just trying to sell something? If they have to rave about how much of an expert they are, that may be a warning sign. If someone is successful in their field, their record will reflect it.

One Size Does Not Fit All

It's hard to find one comprehensive billing book that covers all the topics in the field adequately. All the topics in billing can't be condensed to fit in one book and provide any real substance or useful information.

To learn about the basics of the profession, an introductory book should include: 

• Claim processing - Deductibles, Co-Pays, & Co-Insurance
• Primary, Secondary, & Tertiary Insurance
• Commonly used forms
• Medicare and Medicaid, Workers Comp HMO's, and PPO's
• Reading and Understanding EOB's (Explanation of Benefits)
• Patient Billing
• Aging reports and working accounts receivables
• Terms commonly used
• HIPAA
• Training and what you need to know
• What ICD diagnosis and CPT procedure codes are and how they are used in medical billing

An introductory book on the subject should include a good description of the billing process, responsibilities, and what to expect.

Business

If wanting to start a home business, get a book written by someone who has started a successful billing business or currently operates one. Their advice will be a lot more valuable than someone who writes a book about starting a business and tries to apply it to medical billing. The unique challenges and character of the medical billing business can only be explained by someone who has experienced it.

For useful information on starting a business, a medical billing book should at least cover: 

• Contracts (this could be a separate book in itself)
• How much you can expect to make
• Whats necessary to start a business
• Pricing your services
• Software, electronic claim filing, and the clearinghouse
• Business plan

Marketing Your Services

Marketing a medical billing business is a topic worthy of a book on its own.It's important to find a good source for marketing ideas if starting a business.

Getting a client - this one is very important. One of the biggest challenges when starting a medical billing business is convincing a doctor to give your billing service a chance. What are the credentials of the author? Have they operated a successful business? Do their techniques seem realistic or is it just a thinly veiled attempt to get you to buy a "Business Opportunity", training program, or overpriced practice management software.

Marketing books should cover: 

• Innovative marketing techniques
• How to find clients and what they want to hear
• What to say when you meet with a doctor or office manager
• What services to offer to distinguish you from the competition

In summary if you want to learn about all the different facets of billing, obtain books from a credible source and plan on using multiple resources to reach your career objectives - be it to get a steady job or start a business.

How to Handle Medical Billing Code Changes

Medical billing codes undergo changes on a yearly basis. When they become outdated, insurance companies cannot accept them any more. Your claims will therefore be denied because of the codes.

There are few ways in which you can keep up with changes in medical billing codes. The first thing that you can do to keep updated codes is to use Current Procedural Terminology Code Books. These are billing code books that have an explanation for each medical billing code. They list the codes alphabetically and by number.

The codes found in CPT books are updated annually and the changes may be minimal at times, while at other times they may have a lot of changes. The books also contain a list of modifiers, which indicate that a service was changed in a certain way from the stated current procedural terminology without changing the definition. By ensuring that you have these books on a yearly basis, you will be able to keep up with any billing code changes that have taken place.

You can also handle code changes by using the code book known as the international classification of diseases, ninth revision clinical modification (ICD9). This is a coding system that groups related disease procedures and entities for the reason of reporting statistical information. ICD9 books also list diagnoses both numerically and alphabetically and the codes are updated on a yearly basis.

The other way to handle code changes is to purchase medical coding software, which is a good alternative to code referencing books, which you need to update on a regular basis. The other benefit that medical billing software offers is that you do not need to consult a number of books in order to code a medical procedure correctly. Electronic medical software eliminates the problem and in addition to this, it provides online searching capabilities that you cannot achieve with reference books.

Medical office software is the best method that you can use to handle code changes because it will provide you with more accuracy. Medical offices that utilize online coding and billing software will find it easier to transition from the old codes to the new codes because the software will handle much of the work. By keeping up with code changes in this way, your billing practice will improve the quality of care that you deliver.

Finding the Best Medical Billing Schools

If your dream of being in the hospital billing profession seems like a long shot from where you are now, being able to pick one of the medical billing schools in the country can be the first step to realizing your goal. For starters, you have to understand that medical billing schools are institutions which train professionals in the process of billing and coding. This means that healthcare billing schools will be able to train people professionally in the areas of following up on claims with insurance companies in order for the hospital to receive the payment for the services it rendered. In conclusion, medical billing schools can train people about the basics of insurance policies, communications, legal systems, and other practices in order for the industry to work as smoothly as possible.

But, given the fact that there are a lot of healthcare billing schools in the country today, you might be wondering which one will be the best for you. So, here are some tips in order for you to make the right choices with regard to a medical billing school:

First, make sure that your school of choice is nationally accredited. This means that they have passed, at least, the bare minimum of what the government and the medical industry expects of them. Having a license also means that they are within government jurisdiction. This means that people running the institution can be legally liable in the event that they do something that can be considered fraudulent and bordering on illegal.

Secondly, medical billing schools are supposed to have a strong inclination towards the medical industry. Make sure that your institution of choice has a strong faculty. They should be experts in different fields in order for them to have the credibility in explaining procedures, and ethics involved in the healthcare billing industry. Experts should also help you understand the concept of insurance cycles, and general coding systems. Also they should understand patient confidentiality clauses as well as the HIPAA or Health Insurance Portability and Accountability laws.

At the end of the day, it is safe to assume that the future of healthcare billing is on an upward trend. You just need to decide if this is the right career choice for you.

Understanding Medical Billing Jobs

If you think about it, medical billing jobs are essentially jobs that are mainly responsible for billing and collecting all of the professional fees for healthcare and medical services provided to patients. As such, those in the healthcare billing profession are tasked with sending out claims to insurance companies, posting payments, responding to external information requests related to claims filed, following up on claims without responses, communicating with patients or the insurance companies regarding denied claims, claims in review, or pending reviews, sending out statements to patients, and turning over delinquent accounts to debt collection agencies. Medical billing jobs might not be as simple you think. Billing is generally a simple task but those with these jobs have to be equipped with broad knowledge and understanding of the entire billing process, as well as all rules followed by health insurance companies.

So why should you consider medical billing jobs?

Those in the this profession receive a median salary of around $30,000 every year. That's incentive enough for a lot of people to go and take up training for this profession. What's good also is that healthcare billing jobs do not necessarily mean working in a hospital. Healthcare billing touches up on everything that involves billing that is medical in nature. So that means, jobs in healthcare billing might be available on the end of the insurance companies, doctors offices, pharmacies, and nursing homes. Since insurance concerns touch up from time to time with matters of the law, a medical billing job can also find you working for a law office.

But can't doctors do their own billings?

Technically, yes. But this job requires an entirely different kind of training of the administrative kind that most doctors just don't have the time for. And even if they do find the time to train, the actual process of billing will take up so much of their time that they might not have any left to actually be doctors. It's not like they can do away with billing also that's why there are a lot of medical billing jobs around. Just imagine how many doctors out there will need help. Doctors need medical billers and that opens up opportunities for you.

Getting trained

As with any profession, this career require intensive training. It will be your job to ensure that all bills are free of errors so you have to know everything there is to know about healthcare billing and all related services. You can easily search for medical billing schools online so you can get started on that all-important training as soon as possible.

How Communications Affects the Relationship Between a Provider and a Medical Billing Service

In order for the billing to be done effectively it is crucial that the relationship between the billing service and the provider's office is a good one. Frequent communications with your providers is key to a good relationship. It is important to keep them abreast of everything that is going on with their billing and all that you are doing. When we first started our business we didn't see the point in telling a provider that we were taking care of a denial or appealing a particularly difficult claim. We assumed he knew we were taking care of it. But experience showed us that this is not necessarily true and you need to find a way to keep your providers up to date on the status of their accounts without bothering them.

Some providers say they don't want to know about the issues, but someone in the office should be watching for what the issues are. You don't have to speak to the provider every time you communicate. You can have a weekly fax or email that just gives the highlights of the issues for the week. It is important that they know that any issues that come up are being taken care of and you are showing them this by your weekly communication.

When there is no communications between the provider and the biller, the provider may assume that the biller is not doing that much because the biller isn't telling the provider about all the things that he or she is doing. It is amazing how many things we do for providers that they never realize. If you don't let them know then they don't know you did it and they don't realize all the services they are getting.

We work for many small providers who don't keep track of their claims payments. Their whole perception of what is getting paid and what is not getting paid is based upon two things. Do they have any money in their checking account and the explanation of benefits they get from the insurance carriers. They rip open envelopes and tear off checks. If there is no check some only wonder what happened. They often do not understand the reason codes and have no idea why there isn't a check attached. While we may be resubmitting a claim with a corrected diagnosis or ID#, one eob comes through as a denial before the second one comes through paid. Some doctors never notice that they were for the same claim. They only notice that one didn't get paid.

To keep our providers updated of what we are doing, we send a simple fax or email when we complete the billing for the week letting them know what the issues were. It might read something like this.

Dorothy Winn-has incorrect ID# - do you have a copy of her ID card?

Melvin Black-appealed denial for timely filing with electronic reports

Mara Rosen-clearing house report states she no longer has that Blue Cross policy-so you have new info?

Much of the work you do is not just the data entry of the claims and payments but your providers may not have a clue as to the extent of this other work. If you are in the habit of letting the provider know, they will value you even more.

A lot of times billing services think that if they are not hearing from the provider then he/she must be happy. That is a really bad assumption. They may be thinking anything from "Wow my billing service is great!" to "Man, what are they doing over there? Sitting around playing solitaire?" If you want to be successful you really need to know what they are thinking. The best way is to ask. There is nothing wrong with getting in touch with a provider and saying "things appear to be going pretty smooth from our end. How do you feel they are going? Is there any areas you are concerned about?"

If they are worried about something they should tell you. Then you can either rectify it if it is something wrong, or clarify it if it's a misunderstanding. Many billing services have lost clients based on lack of communication. It's something that can be easily rectified.

Training a Medical Biller

Training to become a medical biller can be overwhelming. Whether you are an employer who needs to train employees or you are looking to become a medical biller, good training is crucial. When we have a new employee the training process is intense. It is important that the new employee learn how we do things, and become as self-sufficient as possible as quickly as possible.

Of course in the beginning mistakes are going to be made. We start out by having an experienced biller sit directly with the new employee and have the new employee watch what the experienced biller is doing while taking notes. The whole time, the experienced biller is explaining step by step what they are doing, why they are doing it, how they accomplish it, and every other detail that the new employee may need to know. They are also explaining our practice management system, our filing system, our system of receiving information, and how we communicate with our providers. There is so much to show them.

Once we feel that they have observed enough, the experienced biller switches places with the new person and gives them a chance to try things out for themselves. The amount of time that a new person watches before they are ready to try it varies greatly depending on their previous experience and how quick of a learner they are. Once they switch places the experienced worker watches every keystroke to make sure they truly understand. Many times they give verbal instructions the whole time until they are sure the new person has grasped the task.

Once they are able to observe without having to give verbal assistance they will allow the new worker to complete a task and then check it over after they are done. This is still time consuming as it's being done twice basically. But we feel it is necessary in order to be sure the new person is doing things correctly. The experienced worker will check over each item and bring any mistakes back to the new person and show them what they've done incorrectly. We find this is a great tool. Learning from visually looking at your mistakes is the best experience you can give someone.

As you can see the training process (at least in our office) is very intense and very disruptive to normal work flow. It takes two people to do the job of less than one really. The process is slow but if you want the person to be effective you need to take the time in the beginning to make sure they are trained properly. When we bring on a new person it is usually several months before they are up to speed and the person involved in their training can go back to their regular duties.

If you want your employees to be good quality employees then you need to take the time to train them. You can't expect them to give you excellent quality if you haven't taught them how to do that. We find that mistakes take a lot more time to correct on the back end than they do to avoid them up front. If you take the time to properly train the person, it will pay off in the end.