Understanding Medical Billing 1

Learning Objectives

  • Understand batch processing and submission of electronic claims.

  • Review reports of claims submitted and prepare paper CMS claims (CMS 1500).

  • Generate secondary electronic claims, particularly to Medicare.

  • Post insurance payments, review patient ledgers, and manage deductible postings.

  • Allocate payments using ERA (Electronic Remittance Advice).

  • Post secondary insurance payments and manage adjustments for denied or non-covered services.

  • Utilize Medical Office Simulation (MOS) software for practical exercises.

Overview of Medical Claims

  • Medical Claim Definition: A bill submitted to an insurance carrier for reimbursement.

  • Claim Submission Process:

    • Occurs post patient registration and after the provider completes notes.

    • Involves adding diagnosis and codes into a practice management system.

    • Claims reviewed by billing specialist before batching them for submission.

Claim Batching

  • Batching Claims: Grouping claims together by:

    • Date of Service

    • Insurance Company

    • Provider

  • Importance of a Batch Number: Provides tracking for payments once claims are processed.

Processing Electronic Claims

  • Billing Manager Interface: Allows for claim batching and submission processes.

  • Criteria for Claim Sorting:

    • Date of Service

    • Billing Status

    • Claim Type

    • Insured status (with or without insurance)

    • Charges and Authorization Status.

  • Electronic claims preferred for their timely reimbursement (7-10 days).

Coding Requirements

  • Claims must be correctly coded with:

    • ICD-10 codes (for diagnoses)

    • CPT codes (for procedures)

    • Clean claims are critical for quick reimbursement.

  • Error Handling: Claims are reviewed for errors (e.g., missing modifiers) before submission.

Submitting CMS 1500 Forms

  • Historical Context: Used for manual submitting of claims; now less frequently used due to electronic processing.

  • Structure of CMS 1500:

    • Outpatient claim form, primarily for outpatient billing.

    • Specific boxes must be completed according to guidelines for different insurance types.

  • Importance of Review: Understanding how to complete and submit this form is critical.

Handling Secondary Insurance Claims

  • Birthday Rule: Used to determine primary vs. secondary insurance.

  • Claims Submission Order: Submit primary insurance claim first, followed by secondary once EOB is received.

  • Explanation of Benefits (EOB): Essential document to accompany claims for secondary billing, outlining payments made.

Timely Filing Guidelines

  • Medicare allows a 365-day window for claim submissions.

  • Other insurers may have stricter deadlines (30-120 days). Failure to meet these results in non-reimbursement.

Explanation of Benefits (EOB)

  • Definition: Document from insurance summarizing treatment and payments.

  • Key Contents of EOB:

    • Payer and provider information, patient details, procedure codes.

    • Billed amount vs. allowed amount, provider's contractual obligation (no balance billing for the difference).

  • Coinsurance and Deductibles: Patients may still owe fees even with multiple insurances due to coverage differences.

Conclusion

  • Understanding of the billing process, coding, and insurance rules is crucial for effective claim management.

  • Continued learning required for advanced billing practices as more topics will be covered in future lessons.