Medical Billing Concept

Medical Billing – Medical Billing is Health Insurance claim process service. This process
start from provider office. The provider sent the medical records to billing
office after done by the service. The Medical billing office create the charge
and failed the claim to the Insurance, than the Insurance verified the
claim and paid the payment to the provider.
(Medical Billing is the practice of submitting claims to Insurance
companies)

Billed Amount – When the provider charged for treatment is known as Billed amount (Billed
amount fixed for Provider Office).

Allowed Amount – Every Insurance of certain the amount for every procedure is known as
Allowed amount. (Allowed amount fixed for insurance company)

Co-Pay - When the Patient pay the amount to the Provider for every visit.
(Co-pay is $10 to $30).

Deductible – Every year the patient must pay some amount to the Insurance, before
Insurance start paying.

Paid Amount – The Insurance Company has paid this amount.

Co-Insurance – A part of allowed amount of the Insurance determined for every service. This
amount must pay by patient or secondary insurance after primary insurance
has been paid.

Write-Off (Contractual Adjustment) – The different between Billed amount and Allowed
amount.
(Billed amount – Allowed amount = Write-Off).

Interest Payment – When the Insurance take more than 45 days for process the claim they
give the Interest payment to the provider.
Capitation – The Insurance Company was given fixed amount to the provider per month,
regardless of medical utilization.
Off-Set – Off-Set is negative payment. If claim has been over paid previously, then there is
adjustment in the current EOB. This adjustment is called Off-Set.

Participating – The provider Contract with the Insurance Company he is called Participating
Provider. Write-Off available and Capitation is eligible. Participating provider
is under covered the HMO plan.
(Will receive the payment within 14 days).

Non-Participating – The Provider doesn't contract with the Insurance company he is called
Non-Participating Provider. Without write-off and Capitation is not
eligible. Non-Participating provider is under covered the PPO plan.
(will receive the payment within 27 days).

HPSA – (Health Professional Shortage Area) this area are few provider. When the
Provider goes for this area the Insurance give the Incentive amount in more than the
payment.

Remit payment – Remit payment is EOB received by electronically.

Fee Schedule – The amount fixed by insurance company for every procedure.

Encounter – The patient contact to the provider for each service is called Encounter.

Episodic Billing – The patient contact to the provider for every service was recorded as new
account is called Episodic Billing.

HMO – Health Maintenance Organization. HMO applicable for the specialist provider and
patient contribution is low. Participating provider is under covered the HMO plan.

PPO – Preferred Provider Organization. PPO only applicable for the PCP (primary care
physician) providers and patient contribution is high. Non-Participating provider is
Under covered the PPO plan.

Out of Pocket – it is normally refer to patient made by payment.

Cross Over – The primary insurance EOB, automatically forward to the secondary
 insurance. Ex:- Medicare EOB forward to the Medicaid insurance.

Collection Payment – When a provider does not receive payment from the patient, he move
through the collection agency.

Budget Payment – The patient pay the payment by installment.

CPT – Current Procedure Terminology. It is used to describe procedure that physician

perform.

ICD – International Classification of Diseases. This is developed by WHO (World Health

Organization) and updated by AMA (American Medical Association). 9th edition, CM is
the Clinical Modulation.

Modifiers - It is two digit alpha numeric codes that attached to CPT code.

Authorization – The provider must receive approved from the staff member of the health
plan medical director, before done by the service.

Referral Authorization # – The number given by authorize the referral, is called referral
authorization number.

File date – When the date of claim has been filed to the insurance. (Insurance filling date)

Check date – When the date of check issue or written.

Deposit date – When the date of the check deposit in the bank.

Batch date – Batch date used for Julian date. (Julian date 365)

Medicare – Medicare is federal Insurance.

Eligibility:-
 above 65 years old
 6 to 10 year federal employees
 physically challenged person
 Shorten life person
 federal tax paid minimum 10 years
Medicaid – Medicaid insurance eligible under the poverty people. The insurance different for
state wise. Medicaid is related to Medicare.

Medicare Payment Structure - Medicare always pays @ 80% of the allowed amount &
balance 20% of the allowed is Coinsurance.

Interest Payments - Interest Payments are paid by the Insurances in addition with the Claim
Payments. They are paid if there is any delay in their side making
payments to the Provider.

Late Filing Charges – Late Filing Charges are deducted at 10% of claim payment when the
Provider files the claim after the Particular filing limit mentioned in the
Contract.

COB - Co Ordination of Benefits. It is the arrangement between the Insurances as which one
is the Primary payer & which one is Secondary. This is because to prevent
overpayment for the claim by both the Insurances.

Take Back – Take Back is the previous Overpayment gets reversed on the same patient.

Workers Compensation – Workers Compensation Insurance covers the work related

Injuries. They reimbursement is based on state workers
Compensation fee schedule. There would be no patient
responsibility. They always pay as Primary Payer. If any health
Insurance paid as primary, the payment should be refunded.

No Fault – No Fault Carrier ( Auto Accident Insurances) covers accident related injuries.
They always pay as primary. If the insurance is not contracted, balance billing
would be there.

Unapplied Cash - If a Patient not found in software, or DOS not found for the Patient, client
would have a suspense Account named Unapplied Money/Cash. We
have to post the payment amount into that Account mentioning Check#,
Patient Name, Payor & DOS. It would be helpful for future reference.

Underpaid/Overpaid – Sometimes, Insurance would pay lesser than or over than the AR
priced amount or Fee Schedule. In future, they would recoup the
previous payment and pay per Fee Schedule. While posting
reconsidered payments, we have to check with the previous
payments.
Medigap – Medigap is a private, Supplementary insurance to fill the gap for the Medicare
coverage

Budled Payment – Insurance company pays the single payment for the n number of CPT is
known as bulk payment

POS – Place of Service. Which the place of the patient takes the treatment is POS. It is also
known as Point Of Service.

DOS (Date of Service) – When the date of the provider service to the patient.

Payment Posting
Step 1

 Received the scanned copies of the EOB.

 Go through the EOB carefully.
 Some EOB are not scanned properly. So read the EOB carefully.
 Check details, Patient details, insurance details are available in the scanned EOB.
 Payment details like billed amount, allowed amount, co-insurance/co-pay, deductible, paid
amount, write-off amount available.

Step 2

 Select the practice (Otho, neurology. Radiology etc......)

 Entered the check details in the software. (Check date, Check #, Check amount)
 Entered the batch number in the software, please entered the batch # carefully.
 Entered the claim or account number carefully.
 Please verify the DOS (date of services), CPT code, modifier codes and billed amount.
 Entered allowed amount, co-pay, Deductible, co-insurance and paid amount carefully.
 Verified the Write-off amount carefully.

Step 3

 Any difference between check amount and paid amount, the check not tallied. (The batch is
incomplete).
 Before posting the bulk check, please verify log sheet amount and total check amount. If, any
difference available please consult. (May be some checks, EOB's are not scanned properly)
Step 4

 How to find the patient? Take the searching option: Date of Birth, Acct #, SSN #, Patient first
or Last name, visit #, DOS, Insurance ID.

 How to find the Acct #? Take the searching option: Date of Birth, Patient first and last name,
Insurance ID.

Step 5

How to post Interest amount?

 We have to Create the dummyAcct# , then to post the specific column and Select the option
(Interest payment). And updated reference (Check #, Scan file date).

Step 6

How to post the Off-Set Payment?

 Off-Set payment is Negative or Excess payment.

 This Amount, posted in payment column. Don't take write-off.
HIPAA – Health Insurance Portability and Accountability Act 1996.

HCFA – Health Care Financial Administration. Covered the patient, insurance details and
procedure, Dx details.

HCPCS – Health Care Financial Administration Common Procedure Coding System.

Super Bill – Covered the patient details and Procedure, Dx details.

POS:-

11 : Office visit.
12 : Home Visit.
20 : Ambulatory surgical service.
21 : Inpatient visit.
22 : Outpatient visit.
23 : Emergency visit.
24 :
25 : Birthing place visit.
26 : Military treatment visit.
31 : Skilled nursing facility visit.
32 : Non Skilled nursing facility visit.

Modifiers:-

22 : Unusual Procedural Services.

25 : Distance service.
26 : Professional Component.
TC : Technical Component.
RT : Right Side.
LT : Left Side.
50 : Bilateral Procedure.
51 : Multiple Procedures.
52 : Reduced Services.
59 : Distinguish provider.
76 : Repeat procedure same physician.
77 : Repeat procedure different physician.
99 : Multiple Modifiers.
AMA – American Medical Association

HMO – Health Maintenance Organization

PPO – Preferred Provider Organization

PIN – Provider Identification Number.

UPIN – Unique Physician Identification Number.

PCP – Primary Care Physician

CMS – Centers for Medicare and Medicaid Services.

EOB – Explanation Of Benefits.

AOB – Assignment of Benefits.

COB – Coordination of Benefits.

ROI – Release of Information.

ROB – Release of Benefits.

EFT – Electronic Fund Transfer.

FTP – File transfer Protocol.

ABN – Advance Beneficiary Notice

BCBS – Blue Cross Blue Shield

CMSPCS – Centers for Medicare and Medicaid Services Procedure Coding System

ECS – Electronic Claim Status

PCS – Provider Claim Summary

NPI – National Provider Identifier

PA – Physician Assistant

PT – Physical Therapist

RA – Remittance Advise
SSN – Social Security Number

TIN – Tax Identification Number

WC – Workers Compensation

ADA – American Dental Association

CNS – Clinical Nurse Specialist

DMERC – Durable Medical Equipment Regional Carrier

FBI – Federal Bureau of Investigation

NDC –

Hospital medical, medigap (medicare + comm.), drug