Surgical Billers

s your office staff spending endless hours submitting medical claims or tracking payments? Is your office submitting claims on HCFA forms instead of electronic? Have you ever been denied a payment due to late submission or lack of authorization for a claim? Do you find your cash flow is suffering while waiting for insurance payments?

If you can answer "yes" to any one of the above questions, it maybe time to consider outsourcing your insurance billing to a qualified medical billing service. Make sure the billing service submits claims electronically, which pays faster than paper claims. Electronic submissions receive reports from insurance companies within two hours of submission, listing the status of those claims. These reports designate which claims were accepted and which were denied. This allows the billing service to make the necessary changes to the rejected claims and resubmit them immediately. Most insurance companies will pay electronic submissions in two weeks from the receipt of the claims.

A qualified billing service will stay current on all the insurance regulations so you don't have to! Just think, no more reading those confusing insurance manuals. A good billing service talks to insurance companies every day, so when they make a mistake (and they make plenty), they know just who to call to correct the error. The billing service should also be current on the fee schedules for the procedures you bill the most. The billing service should know what the reimbursement rates are for each service, so if the insurer pay less, the service call them on it.

What do medical billing services do? Medical billing encompasses, for the most part, all billing and accounts receivable management functions of a given healthcare practice. The major objective is accurately submitting claims and patient statements to receive the correct reimbursement for services rendered in the shortest amount of time. To achieve this goal, the medical billing service will provide some or all of the following:

• Provide a suitable mode of patient information retrieval.
• Set up patient information on their billing system.
• Enter charges for each office visit and procedure.
• If electronically filing claims - transmit electronic claims and receive audit reports.
• Print paper claims for any carrier unable to accept claims electronically.
• Post payments received from insurance carriers and patients.
• Print and mail patient statements.
• If applicable respond to patient calls regarding their account.
• Follow up on any unpaid claims. Patient and insurance aging reports that are produced by most computer programs are valuable tools when reconciling accounts.
• When applicable, print month-end or quarterly production reports: Practice analysis, aging accounts receivable and referral reports for providers.

Outsourcing gives your medical practice the advantage of having full time billing staff without full time salaries, additional costs of benefits, sick and vacation time. Patients can contact our office with any insurance questions or concerns, leaving the medical staff free for other duties and patient interaction.

Ethical Responsibilities for medical billers are important because medical billers are privy to personal and financial information of both your practice and your patients. It's important you choose a biller who will behave in an ethical and legal manner. HIPAA has mandated the standards required of all medical personal with regards to patient confidentiality. It is imperative for all medical practices to adhere to these standards. Click here for the Office of the Inspector General's guidelines on compliance requirements for medical billing services. A qualified medical billing service will present the provider with a confidentiality agreement to meet the HIPAA compliance regiments.

Legal responsibilities for medical billers include all areas of billing. It is illegal to report incorrect information to government-funded programs, such as Medicare, Medicaid, and CHAMPUS. It is the medical billers responsibility not to submit any claim with improper coding or information, and to inform the provider of illegal coding practices. It is imperative the medical billing service monitor all billing with regard to incorrect coding that may be viewed as fraudulent billing. Medical providers can be fined up to $10,000 for each service deemed frequently billed. Medicare deems not billing a patient copayment as fraudulent and an abuse the Medicare system. It is the medical biller's duty to stay current with government regulations and keep the provider in good standing.

Fee Schedules for determining healthcare provider reimbursement. Before the process of billing and the collection of payment can begin, it is essential the medical biller is aware of the various insurance reimbursement fee schedules. The following is what provider reimbursement fees are based on:

• The economic level of the community
• The physician's experience
• The medical specialty of the practice
• Charges of other physicians in the area
• The cost of the service or supply

The maximum amount the insurance carrier or government program will cover for specified services is called the allowable charge. The difference between the physician charge and the allowable charge is called a non-allowed charge. Allowable charges are often based on Usual, Customary and Reasonable fees (UCR).

Usual - The physician's average fee for a service or procedure.
Customary - The average fee for that service or procedure within an area, based on national trends rather than regional or local customs.
Reasonable - A fee that is generally accepted for a service or procedure that is extraordinarily difficult or complicated, requiring more time or effort for the provider to perform.

Providers who participate in federally funded medical insurance programs, such as Medicaid, CHAMPUS/TRICARE, and CHAMPVA, must accept the UCR fee as payment in full. The patient cannot be billed the difference between their fee and the UCR fee. Most private insurance carriers utilize UCR fees but are not regulated under federal law. Therefore, the patient with a private insurance company can be billed the difference.

Is this hard to find a qualified medical billing service? There are several ways to find a qualified medical biller. One is to ask your colleagues for referrals. Another is contact your state or national medical associations for the names of medical billing services. However, this is not always a qualified referral, as the association may not have direct knowledge of the medical billing service's abilities. The Internet is a great resource for researching medical billing services. However you compile your list of medical billing service candidates, remember to find ones with medical billing knowledge in your area of medical specialty. Each medical specialty has it's own insurance regulations governing claim submission and payment. Look for a billing service with experience of at least three years or more. Not everyone who calls themselves a medical biller knows insurance collections. You want to find a company like Surgical Billers that has years of reimbursement experience.

Does the billing service need to be local? The most important aspect of outsourcing to a billing service is their ability to get claims paid in the fast time possible to ensure steady cash flow into your practice. With today's technology, a qualified billing service does not need to be local. However, make sure the company you hire is familiar with your state's insurance regulations.