Basic Medical Terms Your Practice Staff and Patients Should Know

An article from Physicians Practice:
Last week, we talked about the difference and definitions of major insurance types in “Medical Insurance Primer for Practice Staff.” A fellow blogger pointed out that many patients are also not aware of the differences between copay, co-insurance, and a deductible. Below are some additional terms for your staff to have that will easily explain these differences to your patients.
Allowed Amount: Amount of the billed charge the insurance company deems is payable by the plan.
(MORE: Implementing Change in Your Medical Practice) Assignment of Benefits: The patient or guardian signs the Assignment of Benefits form so that the physician or medical provider will receive the insurance payment directly.
Authorization: Approval by the health plan if the physician wants to refer the patient to a specialist.
Bundling: Method by which the insurance company decides to combine payment for two or more medical services.
Capitation: Payment methodology in which the physician is paid a set dollar amount determined by a per member, per month calculation to deliver medical services to a specified group of people (like an IPA).
Carve‐Out: Medical services that are separated from a contract and paid under a different arrangement.
Case Management: A method by which a health plan attempts to control costs by directing all of the procedures for the care of an individual through a nurse or other healthcare professional.
Claim: Request for payment by a medical provider for a given medical service or item.
Consolidated Omnibus Budget Reconciliation Act (COBRA): Continuation of medical benefits once a member has left their employer.
Co‐Insurance: A percentage the patient is responsible for on a given insurance claim.
Contracted Provider (Participating): Provider that has an agreement with a health plan to accept their patients at a previously agreed upon rate for payment. They are deemed as “in‐network.”
Copayment / Copay: A fixed dollar amount an insured person must pay when medical service is received.
Deductible: Set dollar amount which must be satisfied within a specified timeframe before the health plan begins making payments on a claim.
Explanation of Benefits (EOB): Summary of the payment made by your health plan to the medical provider.
Fee-for-Service: Method of payment for medical services rendered.
Fee Schedule: List of CPT codes and dollar amounts an insurance company will pay.
HCFA 1500: Standard claim form used by health plans on which to consider payment to the medical provider.
ICD‐9 / ICD-10: Standard format of identifying the illness, injury, or disease by using a three-digit to five-digit code.
Medical Necessity: Medical procedure or service must be performed only for the treatment of an accident, injury, or illness and is not considered experimental, investigational, or cosmetic.
Out‐of‐Pocket Expense: Amount the patient must pay (and not paid for by the insurance plan).
Pre‐Existing: Medical condition diagnosed prior to the effective date of the health plan.
Usual & Customary: Reduction in the payment of benefits on a claim which is justified by the insurance company as “the going rate” to be paid in that geographical area.
These are the most common ones I receive questions about, can you think of any others that might be helpful?
Keeping this list in a convenient place for your staff is a great tool for them to utilize when communicating with your patients.

Source: physicianspractice.com.
 For more information contact:

Strategic Practice Solutions
Mack Cali Centre II
650 From Rd., Ste 565
Paramus, NJ 07653
Phone - (201) 477-1564
Fax - (201) 549-6316
Email - info@strategicpsonline.com

 

Compare costs, benefits of billing service vs. in-house

Compare costs, benefits of billing service vs. in-house

Question I have been unhappy with my billing service; the money is not coming in as quickly as I think it should. I am considering bringing the billing process in-house. What are the pros and cons associated with this move?
Answer At this time, you are probably having a difficult time identifying the benefits of an outside billing service, and the cost seems high compared with the results. Nonetheless, the decision to transition the billing process from an outside service to in-house requires thoughtful consideration. We recommend you evaluate the benefits and costs associated with both options. Here are some points to consider.
With a billing service, billing and collection activities occur off-site. You won’t have to pay rent on space for a billing department or convert a patient care area to an office.
The billing service is responsible for hiring, training and supervising staff. They also are responsible for coverage when any of their employees are out of the office. And they are responsible for acquiring and maintaining all necessary computer software and hardware as well as addressing other technology-related issues.
HCFA rules and regulations are constantly changing. With the increased focus on fraud and abuse, and the potential implications of the latest publication of the Health Insurance Portability and Accountability Act, it is critical that staff (your practice along with the billing service) stay abreast of the latest requirements. To do so, the billing service will have to provide ongoing training to ensure the staff is current on such things as coding issues, regulatory mandates and HCFA rules.
Billing service companies price their services in different ways. In some instances, fees include postage, forms and other individual items. In other companies, one or more of these costs may be separate from the fee for performing the billing and collection activities. There are usually set-up charges for the service itself, along with those associated with electronic claims transmission set-up.
The primary benefit of having your own billing department is that you have more control over how the billing and collection tasks are handled and the staff that is hired to perform them. You also have more immediate access to management information. However, you need to consider the resources and costs associated with moving your billing and collections process in-house. There are some obvious costs and some not so obvious ones.
For instance, space: Where do you plan to house your billing department? Do you have enough space in your current location? If not, can you expand? If so, what is the cost?
And staff: Can your current staff support all of the billing and collection functions? If so, do they have the appropriate training and experience? If not, how many employees will you need and what will you need to pay them? What will be the cost of ongoing training? How will adding staff affect the office culture? How will you provide coverage during staff absences?
As for technology, do you know what billing software is available and most appropriate for your practice? Do you have the required hardware? Will you purchase or lease the billing software or hardware? Who will be available to monitor the system and trouble-shoot?
Then there are regulatory and legal issues to deal with. What will be the cost of ongoing training for your billing staff; i.e., coding, regulatory updates, keeping up to date on the latest billing and collection methodology and tools? Whether your billing is outsourced or in-house, you will still have to provide staff training to ensure that the practice is in compliance with fraud and abuse regulations and HIPAA requirements.
There are miscellaneous and sometimes hidden costs associated with performing your own billing and collection activities. Some examples include HCFA forms, statement forms, printer maintenance and postage. There are costs associated with hiring and training staff. Another consideration is the potential cost associated with terminating your agreement with the billing service.
You can easily compare the two options once you’ve determined the start-up and annual costs associated with bringing the process in-house; i.e., salaries, benefits, rent, software and hardware maintenance.
Determine how much you have paid to the billing service during the last 12 months or project how much you will pay based on current statistics. If fees are contingent on a certain percentage of collections, project the amount you will pay them in a year by multiplying that percentage by the total receipts for a year.
You should also compare both the gross and net collection rates to regional and national norms for the same specialty.
If you decide to move the billing process in-house, there will inevitably be delays in getting the first bills out, in collecting the billing company’s outstanding accounts receivable, and in the transition with the insurance companies. Can your practice sustain a 20% or more drop in cash flow over several months?
If you are still in a quandary after you’ve evaluated the costs and benefits of each option, meet with the billing service customer representative to discuss your issues and how they can be resolved.
The problem may be as benign as improving communications between your practice and their company. The billing service company’s response to your issues may also play a role in your final decision.
We are not advocating one way or another. Sometimes the decision is not a financial one. The benefits of feeling more in control may outweigh any of the costs. However, it is prudent to have as much information as possible to make the best decision for your practice.

Source: ama-assn.org #health insura

For more information contact: 
Strategic Practice Solutions
info@strategicpsonline.com
201-477-1564