Welcome to the Step by Step: Initiating and/or Enhancing Billable Services Module 2:

The Medical Billing Process.

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- Efficient medical billing processes optimize returns and shorten the revenue
cycle process.

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- Revenue Cycle Management is more than the billing of claims. The process begins at
patient registration and the accurate collection of patient data

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- Having specific policies and procedures for patient registration, insurance and
benefit verification, charge capture, and claims processing is an essential step to
maintaining practice viability.
- Investigate and incorporate automated and software-aided insurance eligibility
verification into current practice/clinic work flows.
- The tracking of patient visits is essential for charge reconciliation (e.g., no
shows)

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- The charge entry process is where claims are actually created.
- Appropriate coding will assist in proper reimbursement.
- Coding is also critical for demographic assessments and studies of disease
prevalence, treatment outcomes and accountability-based reimbursement
systems (e.g., HEIDIS, MACRA)
- Electronic claims submission vs. manual claims submission
• Reduce the amount of time and resources physician practices devote to
manual administrative functions—time that can be better spent with patients
or focused on other practice efficiencies
• Pre-audit claim fields automatically for potential errors prior to submission.

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- Physicians and practice administrators need to be astute in comparing and analyzing
data and should ask for assistance from experienced professionals if there is difficulty in
interpreting any practice/clinic financial reports
- Reports aid in determining areas that need the most focus, especially regarding
revenue, productivity and efficiency
- Establish a broad spectrum of KPIs for long-term success (e.g., gross collection
percentage – total charges/total collections informs a practice of what it collects
relative to each dollar charged

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- Productivity reports can expose opportunities for facilitating dialogue among the
stakeholders in the practice, serve as a catalyst for changes in the operation such as
maximizing revenue through changes in the fee schedule or hours of operation

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- Each A/R report may be formatted differently
- The 0-30 day bucket for both patient and insurance should be the highest totals. This
category represents the most recent claims submitted.
• The next highest will be the 31-60 day totals. Typically most of the claims due will fall
in the 0-60 day period.
• The monies in the 61-90 day bucket should drop off dramatically, especially with
insurance balances.
• The 91-120 day bucket amount should drop as claims are worked, patients are billed,
carrier follow-up is performed and collection efforts are made.
• Generating this report monthly, will demonstrate your progress in each area.

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- The Financial summary provides high level data of the total charges, adjustment and
payment for a specified period of time.
- Provides a quick overview of the practice/clinic’s financial status.

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- A better defined regular process will allow for a more efficient team.
- To streamline work processes and improve workflow, assess all workflows,
looking for opportunities for improvement in each area.

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- There are many steps involved in the medical billing process.
- Each step is an integral part of the process and must be performed properly in
order for the entire cycle to run smoothly.

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- Front desk is a key and pivotal role in the success of the practice/clinic.
- Set goals. For example, patients are to be treated the way you like to be
treated; always interact with a person.
- Set a goal for patient communication to occur within the first sixty (60)
seconds of a phone call or in-person interaction at the front desk.

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- Testing your phone system as a user. This is the easiest way to better
understand the patient experience.
- Assess the equipment and its functionality.
- Front office staff must be trained and b able to operate each piece of
equipment efficiently (e.g., credit card machine, fax, copier, ID scanners, label
printers and multi-line phone systems)

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- A/R backlog and balances have increased dramatically due to the rise in
patient financial responsibility for medical care.
- Many patients are unfamiliar with how their health insurance works or recent
changes in their coverage,
- Prioritize insurance verification.

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-The best performing practices/clinics tend to have more staff available to assist
with the various tasks.

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- Staffing models are not one size fits all.
- Resources will dictate the staffing model.
- Staffing levels will vary based on various factors - size of practice, specialty
and services provided.

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- A billing staff is the intermediary of the operations and accounting departments
of a practice/clinic.

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- Understanding the medical billing process requires specific knowledge coding
and collection processes.
- The billing manager must understand the entire accounts receivable process,
as well as personnel management.

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- The billing manager will not likely be involved in transcribing and coding
patient services. However, he/she must have a strong understanding of the
service being rendered by the practice/clinic and the associated codes.
- Some smaller practices/clinics may have only one medical billing
representative to manage all accounts receivable.

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- Practices/clinics should must submit accurate coding in order to receive proper
reimbursement.
- Provider education and training can reinforce accurate coding of services.
- The practice/clinic should always have internal/external coding reviews to validate
documentation and coding.

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- Although not identical, medical billing clerk and medical coder positions are
often combined due to the similarity and required expertise for these roles.

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- The process requires attention to detail and accuracy of data entry.
- When charges are entered, the insurance and patient demographic
information should have been entered accurately in the billing system.

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- Instituting an effective reconciliation process is important process that should
not be overlooked.
- Missing charges (e.g., appointments that do not have charges posted, lost
encounters, unclosed chart notes in EMR) has a large impact on the
practice/clinic’s overall financial performance.

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- The Claim Submission Clerk works closely with commercial and government
payers to ensure the practice/clinic receives the maximum reimbursement.
- Claims must be submitted accurately and timely.

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- When billing problems arise, the Claim Submission Specialist will assist with
rejections, appeals and corrections.

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- The payment posting process affects many other functions of the medical office
and can have a major impact on patient satisfaction, efficiency, and overall
financial performance.

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- A Payment Posting Clerk must be able to spot trends and issues hidden in the
payment amounts and EOB comments.

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- This position requires attention to detail, organization and the ability to work
independently in determining the hierarchy of A/R account follow-up.

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- The A/R Clerk has frequent verbal and face-to-face interactions with patients
and insurance carrier representatives.
- Must have strong customer service skills.

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- The quality of the staff is more important than the quantity of staff members
available.
- A solo physician practice seeing an average of 30 patients per day (without any
ancillary services), may have as few as three (3) staff members (e.g., manager, front
desk, and MA) and maintain an effective and efficient work flow.

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- A good outsourced medical billing service will provide feedback regarding:
- Ways to increase productivity and profitability
- Monitoring performance standards of staff, both in the office and the
outsourced staff
- Ensure the outsourced billing service is performing all the duties as outlined in their
contract.

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Reference: Case Studies. (n.d.). Retrieved from
http://www.revenuecyclesolutions.com/communications/case-studies/

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