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Understanding Medical Coding and Billing

Medical coding and billing professionals usually work behind the scenes, which means that in comparison with medical care providers, they do not get a lot of limelight. While many don’t mind, it is valuable to highlight how much they improve the efficiency of the healthcare system. The medical coding and billing practices that are currently in place streamline the care process experienced by both providers and patients.

Medical Coding

A Brief History of Medical Coding as We Know It

Medical coding has its roots in 17th century England. Data about disease were collected and assigned numerical codes. These London Bills of Mortality were then used to assess the most recurrent causes of death. From their institution until the late 1830s, the bills’ greatest flaw was the lack of consistency in their terminology. At that time, British Epidemiologist Dr. William Farr instituted a uniform classification system. 

These improved bills served as the precursor to the International List of Causes of Death, which was fully realized by the 1930s. The list began to be used by the World Health Organization in its monitoring of international epidemiological phenomena, especially as the list further evolved into the International Classification of Diseases (ICD), which began in 1977 to collect disease and injury data beyond only that which resulted in death.

This change especially has expanded medical records and their usefulness exponentially, and a contemporaneous technological breakthrough made it possible. The commercially-available computer improved the efficiency of medical records and billing in a way that was desperately needed. Now search terms through databases are readily available, instead of spending valuable time searching through thick medical code books. This is not only more time-efficient, but also more cost-efficient, since new copies of such books do not need to be checked, updated, and reprinted each year to stay up to code.

The greater availability and specificity of diagnostic classifications provided by the current medical coding system allows medical personnel to provide more extensive and therefore better care. The current system, called ICD-11 since January of this year, has gone through many revisions to be as accessible and accurate as possible (hence the -11). Currently, there are over 140,000 ICD-11 codes.

Medical Coding

How Do Medical Coding and Billing Meet?

Medical coders convert a patient’s medical experience into corresponding ICD-11 codes. They serve as translators so the billing process can be precise and does not get bogged down by medical terminology. Coders then send the codes to a medical biller, who is responsible for using the ICD-11 codes provided to create an appropriate bill. They first create a claim for the patient’s insurance company, which the latter then evaluates and returns. It is then up to the biller to determine how much the patient owes out of pocket.

This system of designating medical coding, billing, and insuring to different entities streamlines the record-keeping and financial aspects of healthcare. It allows medical professionals like doctors and nurses to concentrate on treating patients.

The Benefits of Outsourcing Medical Coding and Billing

More Dedicated Patient Care

When medical billing is outsourced to a designated firm, medical staff can focus on their patients, instead of feeling split between caregiving and administrative duties. Everyone at a healthcare facility benefits from this: patients can receive the dedicated care they need, and medical personnel can do what they do best.

Improve Customer Service

The other side of the coin also applies. If medical billing is performed by a third party and not a nurse that feels the need to race off to attend to patients, the people in administrative roles can give patients calling with non-medical questions a better experience. People calling to verify their coverage can have their questions answered in a more focused manner.

Medical Coding

More Efficient and Compliant Claims Processing

Because all of the medical coding and billing is performed by someone dedicated to do them, outsourcing the processes saves a medical facility money and time. Everything is sure to be processed in the same way and in ways that are up to code.

Fewer Mistakes

Mistakes in the medical billing process have tremendous dividends. Sometimes they are not discovered immediately, which can cost a patient or practice thousands of dollars. The paperwork is also notoriously difficult to clean up, and the process can take years. Because designated medical coders and billers can do their work without dividing their attention between it and patient care, outsourcing medical billing yields fewer mistakes and is more efficient at protecting patient information. 

Boost Productivity

Without having to jump back and forth, separating caregiving and administrative work allows staff on both sides to be more productive. This can save a clinic or hospital a lot of money while providing better patient care. To outsource your medical coding and billing, reach out to Aspen Ridge Medical today.

Filed Under: Medical Billing

With the financial systems of our medical institutions as nuanced as they are, taking precautions against healthcare fraud must be equally as nuanced. Fraud cases cost medical practices substantial expenses in investigations and loss of reputation and business. Accordingly, all medical practices should have established plans to avoid fraud and protect themselves and the patients they serve.

Healthcare Fraud

What is Healthcare Fraud?

Healthcare fraud is defined by HIPAA as deliberately and willfully implementing or attempting to affect schemes to abuse the health benefits of medical programs or acquire any of the financial assets using fraudulent claims, presentations, or promises. If someone seeks to utilize or circumnavigate established healthcare systems for their own personal gain, it is considered healthcare fraud.

Legal Provisions Against Fraud

There are three major laws that are specifically designed to limit fraud in healthcare settings. These serve as primary pillars of and corollaries to more general fraud legislation. 

Federal False Claims Act

The Federal False Claims Act is the United States government’s primary piece of legislation against fraud. First implemented during the Civil War, the act imposes civil responsibility on individuals who deliberately submit or initiate the submission of fraudulent claims to the federal government. Under the False Claims Act, whistleblowers are provided with job protection under the qui tam provision if they are filing against a party that has defrauded the federal government.

Anti-Kickback Statute

The Anti-Kickback Statute is designed to inhibit those who solicit compensation or give or accept remuneration for services provided by federal health programs. In other words, the statute brings legal action against those who incentivize referrals of federal healthcare programs. Intentional or complicit remuneration prohibited includes drugs and supplies and other non-cash incentives.

Healthcare Fraud

Physician Self-Referral Law

Also referred to as the Stark Law, the Physician Self-Referral Law forbids provider referral to receive services payable by Medicare or Medicaid at an entity in which the provider has a financial relationship. This may include services in which a physician or immediate family member has ownership, an investment interest, or a reimbursement arrangement. Providers who violate this law may face fines in addition to exclusion from participation in federal healthcare programs. According to its strict liability statute status, proof of specific intent to violate the law is not required to bring legal action against the party in question.

Recommendations for Providers

The Office of Inspector General (OIG) offers several suggestions to providers for protecting against healthcare fraud and responding in its event. Follow these to promote compliance within your organization and trust both among staff and clientele. 

A Designated Plan

A stringent plan of compliance is a strong defense against healthcare fraud. This plan should include policies which support a healthcare facility’s adherence to enforcement and which innumerate methods to combat suspected fraud, i.e. claims processing. Make sure that contingency measures and regulations are written clearly and policies are defined adequately. The plan of compliance should be distributed effectively among the staff and trained upon regularly. 

Chain of Command

Have designated individuals to whom employees may go to report suspicious activity. A Chief Compliance Officer at minimum is a necessity, and other personnel responsible for monitoring organization and compliance should be available resources to ensure efficient communication and above-board procedures and transactions. These individuals should report to the governing body of the clinic or hospital.

Detailed Reporting Strategies

Procedures for medical fraud reporting should be well-maintained and documented. They should also be easily accessible to staff; consider the use of a hotline. Make anonymity protection measures a priority to foster immediacy and candidness when fraud is reported. 

Defined Response Procedures

Have an established framework in the event of health fraud and abuse charges. Make all employees aware of the disciplinary steps, up to and including termination and legal action, against those who breach compliance laws and policies. 

Healthcare Fraud

Frequent Audits

As with all good business practice, implementation of reviews and audits to monitor compliance tends to improve adherence. Track enforcement assiduously to minimize more serious auditing problems. In the event that employees must be retained or terminated due to reasons of fraud or noncompliance, ensure that investigation and remediation are systemic and thorough, taking measures to improve policy implementation if such is found to be necessary.

Guard Against Fraud

To protect your clinic or hospital against healthcare fraud, reach out to our medical billing services at Aspen Ridge Medical. We adhere to strict compliance policies to maintain ethical billing procedures to prevent fraud and abuse in the healthcare practices we serve. Give us a call today to begin.

Filed Under: Medical Billing

Medical billing is a necessary part of our healthcare system, and you can’t talk about one without the other. Proper billing ensures that you and your employees get paid for the services they provide. However, you don’t want to be so consumed with the financial aspect of having a medical practice that you can’t offer proper medical support. It then begs the question, can you outsource your medical billing? The short answer is absolutely. The slightly longer answer is not only can it—it probably should be. Why should you outsource your medical billing? We have six compelling reasons.

Outsource Your Medical Billing

Lower Costs

Let’s first address the elephant in the room. Despite what some may think, the cost of outsourcing medical billing is not prohibitive. In fact, it can be very cost effective when you consider the other expenses it renders inconsequential. No matter how many billing claims your private practice has to make, a dedicated billing company has many, many more. What this means for you is that medical billing companies can take care of each bill at a fraction of the cost a private practice would have to pay. These savings get passed on to you.

You can also save on things like equipment, billing software, and office supplies, as well as salaries and benefits of billing consultants and employees not attending to patient care. Employees need to be paid irrespective of how many patients come in for treatment, making salaries a fixed expense. In contrast, outsourcing billing services charge a percentage of the bill—a variable expense—meaning the bill you pay is proportional to the number of claims you file, fewer claims, smaller bills.

Handling Tricky Billing Issues

One of the benefits of outsourcing medical billing services is that someone specifically trained to do so handles the less appealing parts of financial transactions. If bills are not paid on time, a medical billing company is equipped to handle the situation. They can also take care of rebilling in the case of mistakes or rejections. Save yourself the headache and worry, and let our experts manage it.

Outsource Your Medical Billing

Get Paid Faster

The expertise of a medical billing outsourcing company is, unsurprisingly, billing. All our time and resources can be devoted to the billing process, correcting any mistakes or attending to any changes. This means that less time is spent in tedious bookkeeping and money gets back to you sooner.

Improved Returns

Billing companies have been known to perform 15% better at collecting bills than private practice billing departments. That is money that goes directly into your coffers. A billing company can also mitigate the cost of unpaid bills (an unglamorous part of running any business) significantly because they devote all their attention to the billing process. This means your practice will be more profitable when you outsource your medical billing services instead of taking care of them in-house.

By the Book

When you outsource your medical billing, you choose to have consistency in your records. We have prescribed methods and procedures, so you can be sure the work is being done the same way every time. This will not necessarily be the case if you recruit in-house employee(s) to attend to it as they can. Even if you hire a dedicated person to handle the billing, that person may leave the practice, and you will be back to square one. 

Medical billing companies have fewer mistakes to contend with as a general rule because professionals, not temp employees, take care of the details. They are also regularly trained in any procedural changes to ensure billing compliance. The standard of what is required in billing paperwork and procedures changes with regularity, so if you do not outsource your medical billing, you should expect to devote time routinely to research to make sure you are current.

Outsource Your Medical Billing

Keep Your Focus on Healthcare

The most important effect of choosing to outsource your medical billing is that you will have more time to focus on treating patients. Submitting your own bills is never just a matter of paperwork. Correcting errors, monitoring the process, and doing fee reviews also require attention, and while you do that, patients who need your help are not receiving it. Free up your time for patients and their care and outsource your medical billing.

At Aspen Ridge Medical, we provide medical billing services for small practices as well as larger offices. If you let us manage the tedium of billing, you can get back to doing what you do best: offering quality care to your patients. Give us a call today to learn how you can outsource your medical billing.

Filed Under: Medical Billing Tagged With: medical billing, outsourcing medical billing

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