New Patient or Established Patient ?

Who is a New Patient ? When do we bill a New Patient ? When does a Patient become an Established Patient ? These are some of the questions that confuse some practices when billing New/Established patients.

There are instances when a patient is seen by a Physician in the Hospital and in the Office and many Practices are not clear as to how to bill the patient visit. 

Determining whether a Patient visit is to be billed as a New Patient visit or an Established Patient visit has significant implications from a Clinical, Financial, Billing and Coding standpoint.

"A New Patient visit is an evaluation and management service provided to a patient who has not received any face-to-face service from any physician of the same specialty who belongs to the same group practice for at least three years".

Conversely an "Established Patient visit is an evaluation and management service provided to a patient who has already received any face-to-face service from any physician of the same specialty who belongs to the same group practice in the last three years".

An established patient is one who has received professional services from the physician/qualified health care professional or another physician/ qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years - See more at: http://www.aap.org/en-us/professional-resources/practice-support/Coding-at-the-AAP/Pages/New-Vs-Established-Patient.aspx#sthash.O0LGrQSh.dpuf

New Patient visits

1. Patient John Doe comes to see Dr A in his practice after a period of 4 years.

2. Patient John Doe was seen by another physician belonging to a different specialty in the same multispecialty practice, but Patient John comes to see Dr A for the first time.

Established Patient visits

1. Patient John Doe comes to see Dr A in his practice for the first time, Dr A has never seen Patient John before but Dr B another physician in Dr A's practice has seen patient John last year.

2. Patient John Doe was seen by Dr A in the hospital a month ago, he comes to see Dr A in his practice for the first time. Since Dr A has seen patient John within the last 3 years, the office visit becomes an Established visit.

E&M and other Procedures

In a Patient encounter we might perform procedures apart from the regular E&M procedure, in such instances payors would deny the E&M procedure but would pay the additional procedure alone.

Let us take an example of an encounter where a Trigger Point Injection (CPT 20553) is given and an E&M procedure (99213)  is also performed.

The procedure 20553 has an Evaluation component built into its reimbursement, this is the reason why payors may deny the payment for the E&M procedure. So the Payors are right in denying the E&M procedure if the E&M procedure is not distinct and not separately identifiable from the other procedure performed.
 
But We are definitely allowed to bill a Procedure (20553)  and a distinct E&M service (99213) on the same visit, as long as the E&M service is separate and distinct from the procedure, and the same is documented in the progress notes. A distinct E&M service refers to an evaluation where the service is significant and separately identifiable from the other procedure.

An example would be :  

20553        Trigger point Inj                                 
99213 - 25  E&M service for  HTN, DM, CAD   
 
Here the E&M service is separate and distinct from the Procedure 20553, the E&M service needs to be submitted with modifier 25 to indicate that it is separate from the other procedure performed. If the E&M service is submitted without the 25 modifier, it would be denied.

E&M Coding & Documentation Guidelines

It is essential that we code and document every patient encounter accurately so as to maximize revenues and avoid potential audits and recoupments later. It is imperative that we document all procedures that are performed. Any procedure that is not documented would be considered as not performed by the payors.

While coding the E&M codes, we need to be careful in choosing the right level of code. We should choose the right E&M code level based on the Complexity of MDM (Medical decision making that is involved in the evaluation of the patient), once we arrive at the level of code based on the level of medical decision making : MDM, we need to ensure that we have sufficiently  documented the progress note  to support the required level of History and Physical Exam.

For e.g if you see a Patient for f/u in hospital for whom the MDM is moderate then as per MDM which points to level 2, we should code only level 2 CPT 99232 and we need to document a EPF (Expanded problem focused) History and an EPF Exam, this would ensure that we comply with regard to Coding and Documentation
guidelines

Instead for the same patient if we have not adequately documented the progress note, let us assume that we have documented only a PF History and PF Exam and have billed CPT 99232, then we may get paid for CPT 99232, but in case of an audit later, CMS / other payors could recoup the payment for inadequate documentation

Another scenario for the same patient would be wherein,  we have documented more than what is needed, let us assume that we have documented  a Detailed History and a Detailed Exam and have billed  CPT 99233 instead of CPT 99232 as per MDM, then again CMS / other payors may recoup the payment for lack of medical necessity / upcoding.

Hope the above examples give you some idea as to Coding the levels and the documentation required. Please refer the below link for CMS manuals  on Coding and Documentation.   http://www.cms.gov/Outreach-and-Education/Outreach-and-Education.html

Prolonged Services codes CPT 99354 - 99357

Prolonged Services billing is allowed by Medicare in the Office, other Outpatient and Inpatient settings, the Prolonged Service codes are used as add-on codes to E&M codes to indicate the extra time that the Physician has spent face-to-face with the patient.

The Prolonged Service codes are billed based on the length of time spent with the patient beyond the usual time required for the E&M code billed, the time spent with the patient need not be continuous but it must be time spent in one calendar day and must be time spent face-to-face with the patient.

For Office/Outpatient settings :

CPT 99354 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code. Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99355.

For Inpatient settings :

CPT 99356 can be billed when the provider spends direct face-to-face time of more than one hour beyond the usual service/typical time for the E&M code.
Additional 30 minutes of face-to-face time with patient can be reported by CPT Code 99357.

Prolonged service cannot be billed when the prolonged service duration is less than 30 minutes as then it would be considered as included in the E&M code billed.

Prolonged services of less than 15 minutes beyond first hour or less than 15 minutes beyond the final 30 minutes cannot be billed.

Total time of Prolonged services	Outpatient	Inpatient
(do not include visit code time)	Prolonged Services Code	Prolonged Services Code
Less than 30 minutes	Not reported	Not reported
30 – 74 minutes	99354	99356
75 – 104 minutes	99354 and 99355	99356 and 99357

As regards the documentation, the documentation needs to be explicit, documentation is required to be in the medical record about the duration and content of  the medically necessary evaluation and management service and prolonged  services that you bill. 

You must sufficiently document in the medical record that you  personally furnished the direct face-to-face time with the patient specified in the CPT code definitions.   The progress note has to have the start and end times of the visit, along with the date of service.

Hemodialysis & E & M visits

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Key Indicators

Knowing whether your practice is doing well financially is important for the successful running of any practice. Many practices flounder and go bankrupt because they were not monitored properly, leading to their financial ruin.

There are some key indicators which would guide us to make major course corrections where necessary, to bring the practice back on track. Monitoring these key indicators on a regular basis, will ensure that your practice remains financially healthy and continues to run smoothly.

Visits :
The number of Patient visits per month is a straightforward indicator, that is directly proportional to the monthly revenue.

New Patients :
Practices need to ensure that the percentage of New Patients to the total monthly visits is on the increase or steady, on a monthly basis, this would ensure that Old Patients dropping out are compensated by the New Patients, otherwise we would see a drop in the monthly revenue of the practice. When we see the percentage of New Patients decreasing on a monthly basis, this should serve as a warning for us to make course corrections in our practice.

Payor Mix :
An analysis of the Payorwise monthly collections will help us to identify which Payors contribute the most to the revenue of the practice and which payors will significantly impact the practice when their reimbursements change.

Days in AR :
Practices need to know how many days it takes, for them to collect one days charges. The days in AR reflect how quickly and efficiently the practice is able to work the AR and get paid. Higher the Days in AR could be due to a whole host of problems such as Charge / Demographic entry errors, Coding errors,  delayed claim submission, not working the clearing house reports, improper handling of denials and poor AR management. Practices should aim to keep the days in AR under 40.

AR aging :
The AR bucketwise aging is an indicator of how the AR is distributed across different buckets. We can have upto 70% AR (70% of Average monthly charges) in the 0-30 day bucket, upto 15% AR in 30-60 day bucket, upto 10% AR in the 60-90 day bucket, upto 5% AR in the 90-120 day bucket and upto 25% AR in the 120+ days bucket. High AR in the 0-30 day bucket could be due to Charge entry errors, Demographic entry errors, Coding errors or delays in claim submission, high AR in the later buckets could point to improper denial / AR management.

Gross Collection Rate :
The ratio of Actual Collections to Total Charges for a month would be a good indicator of how well we are collecting against the total charges billed. But this ratio needs to be reviewed based on your contractual adjustments. So if you are overbilling your allowed amount by 180 % then a Gross Collection Ratio of 45-50 % is fine.

Net Collection Rate :
The ratio of Actual Collections to Net Charges (Total Charges Less Adjustments) for a month would be a more accurate indicator, than the Gross Collection Rate, of how well the practice is collecting its receivables, since this ratio measures Actual Collections against Actual Collectables, practices should aim for a ratio of 95% or higher.

Preventive Services

Medicare has been reimbursing certain Preventive Services such as Annual Wellness Visits, Cardiovascular Disease Screenings, Diabetes Screening Tests, Screening Pelvic Exam, Glaucoma Screening, Smoking and Tobacco Cessation Counseling e.t.c for some time now.

Recently Medicare has started covering for Screening and Behavioral Counseling to reduce Alcohol misuse and Face-to-Face Behavioral Counseling for Obesity.

Alcohol misuse :

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women.

Obesity Therapy :

Effective for claims with dates of service on or after November 29, 2011, CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submitted with one of the following place of service (POS) codes: 11 – Physician’s Office, 22 – Outpatient Hospital, 49 – Independent Clinic or 71 - State or Local Public Health Clinic.

For more information on Medicare preventive services, visit http://www.cms.gov/PrevntionGenInfo on the CMS website.
For more information on Medicare Learning Network® (MLN) preventive services educational products, visit  http://www.cms.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.

Source CMS

Referral vs Authorization

A Referral is not the same as an Authorization. 

In general a referral is required when a PCP refers a patient to a specialist in-network provider for consultation, while an Authorization also known as Prior Authorization, is approval from the Insurance plan for the performance of certain specific medical procedures and services, based on medical necessity.

A typical scenario would be a PCP referring a patient to a in-network Nephrologist. A referral would be required without which the Insurance plan will not pay. If the Nephrologist performs only an evaluation, the referral alone would suffice, but if the Nephrologist chooses to administer a Procrit injection, than this procedure ( which is on the Prior authorization list of the Insurance plan ) would require a Prior authorization for the Insurance plan to make payment.

Referral :

• A referral is required when a PCP refers a patient to a specialist
• HMO Plans in general require a referral while PPO plans do not require a referral
• A referral is valid for a certain period and for a certain number of visits
• A referral is not required for Emergency services
• A referral is not required for Routine / Preventive services
• Without a referral the insurance plan will not pay

Prior Authorization :

• A Prior authorization is required when a provider plans on performing a procedure which is on the Prior authorization list of the Insurance plan
• A Prior authorization needs to be obtained from the Insurance plan before the performance of the medical procedure
• A Prior authorization is provided by the Insurance plan when they are satisfied as to the medical necessity of the procedure
• A Prior authorization is not required for Emergency services
• Without a Prior authorization the Insurance plan will not pay for procedures that are on its Prior authorization list 

Annual Wellness Visit

From January 1, 2011 Medicare has initiated the Annual Wellness Visits. Medicare uses the codes  G0438 and G0439 for these wellness visits.

G0438 Initial visit 

Annual wellness visit, consisting of  a personalized prevention plan of service (PPPS), first visit.

G0439 Subsequent visit

Annual Wellness visit, consisting of  a personalized prevention plan of service (PPPS), subsequent visit.

Annual Wellness Visits can be for both new or established patients. The initial AWV, G0438, is used for patients enrolled with Medicare for more than a year.

A patient becomes eligible for their subsequent AWV, G0439, a year after the initial visit. During the first year a patient has enrolled with Medicare the patient is eligible for the Welcome to Medicare visit or IPPE, Initial Preventive Physical Exam. This visit is billed using HCPCS code G0402. The Annual wellness code of G0438 should not be used in this scenario  and will be denied since the patient is eligible for the Welcome to Medicare visit G0402 during the first year.

Initial Annual wellness visit consists of,

– Medical and family history

– List of current  providers

– Height, weight, BMI, BP and other parameters

– Detection of cognitive impairment

– Review risk factors

– Review of functional ability

– Establish a written screening schedule for next 5-10 years

– Establish list of risk factors

– Provide advice and referrals to health education and preventive counseling services

– Other elements as determined by the Secretary of Health and Human Services

The above list is just a summary. Check out http://www.cms.gov/MLNMattersArticles/downloads/MM7079.pdf for additional information and links to other Medicare resources on services that must be provided at the AWV and subsequent AWV.

"Incident to" Services

“Incident to” services are defined as services commonly furnished in a physician’s office, which are “incident to” the professional services of a physician or a Non-Physician Practitioner (NPP) and provided by auxiliary personnel.

"Incident to" is a Medicare billing provision that allows services provided by PAs in an office or clinic setting to be reimbursed at 100 percent of the physician fee schedule by billing using the physician's NPI. The Medicare Benefit Policy Manual defines "incident to," in part, as "services furnished as an integral although incidental part of a physician's personal professional service." This is limited to situations in which there is direct physician/non-physician personal supervision. This applies to auxiliary personnel under the supervision of the physician/non-physician, which includes, but is not limited to, nurses, technicians, therapists, NPPs, etc.

Requirements for “incident to” are:

• The services are commonly furnished in a physician’s office.
• The physician must perform the initial patient visit and ongoing services of a frequency that demonstrate active involvement of the physician in the patient’s care, thereby creating a physician service to which the non physician provider's services relate.
• There is direct personal supervision by the physician of auxiliary personnel, regardless of whether the individual is an employee, leased employee or independent contractor of the physician.
• A physician must be on the premises, but not necessarily in the room, when incident-to services are performed.
• Incident-to services cannot be performed in the hospital.

Direct supervision in the office setting does not mean the physician must be present in the same room with his aide. However, the physician must be present in the office suite and immediately available to provide assistance and direction throughout the time the aide is performing services.

A B N Revised by CMS

CMS is notifying health care providers and suppliers that it has updated its Advance Beneficiary Notice of Noncoverage, or ABN form and made the revised form and information on how to use it available online.

Use of the revised ABN, which is issued to patients by physicians and other health care professionals, "in situations where Medicare payment is expected to be denied," will become mandatory on November 1, 2011. At that time, the old ABN form will be considered invalid, by CMS. 

Using the appropriate ABN form is critical to physicians getting paid, physicians would be well advised to start using the revised form before the deadline.

Physicians need to check the lower left hand corner of the document for the words "Form CMS-R-131" and the revised date "03/11" to ensure that they have the revised form in hand.

Practices must have a current and properly executed ABN, because if Medicare denies the services, the physician can't go back and collect payment from the patient. 

http://www.cms.gov/BNI/02_ABN.asp

Foot Care Coverage Guidelines

Covered foot care services

According to the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 290, Medicare-covered foot care services only include medically necessary and reasonable foot care.

Exclusions from coverage 

Certain foot care related services are not generally covered by Medicare. Whether performed by a podiatrist, osteopath, or doctor of medicine and regardless of the difficulty or complexity of the procedure, the following services are not covered by Medicare:

• Treatment of flat foot
• Routine foot care
• Supportive devices for feet

Colonoscopy Billing Guidelines

A Colonoscopy is an exam that allows a doctor to closely look at the inside of the entire colon. The doctor is looking for polyps or signs of cancer. Polyps are small growths that over time can become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a colonoscope.

Colonoscopy Codes

CPT Code
Description
45378
Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)
45379
Colonoscopy, flexible, proximal to splenic flexure; with removal of foreign body
45380
Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple
45381
Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injection(s), any substance
45382
Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45383
Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45384
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45385
Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique

45378 – Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without collection colon decompression (separate procedure).  Because this code is diagnostic and a separate procedure, it should never be reported with any other colonoscopy code.  Per the CPT manual, when a diagnostic endoscopy is followed by a surgical endoscopy, the diagnostic endoscopy is considered part of the surgical endoscopy and is not to be separately reported.  Only when the provider performs a diagnostic colonoscopy with brushings, washings and/or decompression and nothing else (no biopsies, excisions, etc.) should this code be reported.

45380 – Colonoscopy, flexible, proximal to splenic flexure; with biopsy, single or multiple. The physician performs colonoscopy and obtains tissue samples.  This code can only be reported once regardless of the number of biopsies.  According to CPT Assistant, July 2004, this code is also used to describe polypectomy with cold biopsy forceps.  A cold biopsy with forceps is not the same as hot biopsy forceps and it is not a snare technique, therefore codes 45384 and 45385 would not be appropriate.  If the physician does remove a polyp or other lesion with a different technique and then takes a biopsy on a separate lesion, this code may be reported in addition with modifier -59. 

45381 – Colonoscopy, flexible, proximal to splenic flexure; with directed submucosal injections(s), any substance. The physician injects a substance into the submucosa, directed at specific areas through the scope while viewing the colon. (E.g. saline, India Ink).  This code is not to be used for injections used to control bleeding.  45381 may be reported in addition to other procedures with modifier -51 or -59. 

45382 – Colonoscopy, flexible, proximal to splenic flexure; with control of bleeding (e.g. injections, laser, stapling, plasma coagulator).  This code is used when a physician controls bleeding in the colon due to a condition such as diverticulosis.  This code is not used to report control of bleeding caused by a procedure performed during the same encounter.  For example, there may be small amount of bleeding after a polyp is excised.   This would not be reported because control of bleeding is integral to therapeutic or surgical procedures.  However, if the physician treated a bleeding condition and then removed a polyp at a different location, the services may be reported together with modifier -59. 

45383 – Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amendable to removal by hot biopsy forceps, bipolar cuatery or snare technique.  This code is used when a physician ablates tumors, polyps or other lesions by laser or other method (e.g. fulguration).   

45384 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cuatery.  Hot biopsy forceps (also called monopolar cautery forceps) have “jaws” that are between 1 and 2 mm in size and can open up to about 1 cm wide to encompass a small polyp or lesion. The physician then applies cautery to ablate the base of the polyp (or other lesion) so it can be retrieved and sent to pathology for analysis. 

45385 – Colonoscopy, flexible, proximal to splenic flexure; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique.  Snaring involves “lassoing” a polyp or lesion with a wire loop and shaving it off the bowel wall.  The snare may or may not be heated.  Any snare technique including cold snare, hot snare, and bipolar snare would be reported with this code.  The snare technique is the most often used technique and is best when removing both sessile polyps (those attached by a large base) and pedunculated polyps (those attached by a stalk).

Coding Multiple Procedures

When more than one procedure is performed using the same technique, report only one code.  For example, if the physician removes multiple polyps throughout the colon with snare technique, 45385 can be reported only once. 

However, if multiple polyps or lesions are removed with different techniques, you may report each separately.  For example, a physician removes a polyp with snare technique in the rectum and then biopsies a lesion in the transverse colon, you may report 45385 and 45380-59. 

In the absence of a CCI edit, always list the procedure with the highest RVU first.

Sigmoidoscopy Billing Guidelines

During a Sigmoidoscopy, a doctor closely looks at the lower parts of the colon, called the sigmoid colon and the rectum, for signs of cancer or polyps. Polyps are small growths which can over time become cancer. The doctor uses a thin (about the thickness of a finger), flexible, hollow, lighted tube that has a tiny video camera. This tube is called a sigmoidoscope.

The colon comprises three main parts: the ascending colon, the transverse colon, and the sigmoid colon—sometimes called the descending colon. The sigmoid colon is the last one-third of the colon. Flexible sigmoidoscopy enables the doctor to see only the sigmoid colon, whereas colonoscopy allows the doctor to see the entire colon. 

CPT Code
Description
45330
Sigmoidoscopy, flexible; diagnostic, with or without collection of specimen(s) by brushing or washing (separate procedure)
45331
Sigmoidoscopy, flexible; with biopsy, single or multiple
45332
Sigmoidoscopy, flexible; with removal of foreign body
45333
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by hot biopsy forceps or bipolar cautery
45334
Sigmoidoscopy, flexible; with control of bleeding (eg, injection, bipolar cautery, unipolar cautery, laser, heater probe, stapler, plasma coagulator)
45335
Sigmoidoscopy, flexible; with directed submucosal injection(s), any substance
45337
Sigmoidoscopy, flexible; with decompression of volvulus, any method
45338
Sigmoidoscopy, flexible; with removal of tumor(s), polyp(s), or other lesion(s) by snare technique
45339
Sigmoidoscopy, flexible; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique
45340
Sigmoidoscopy, flexible; with dilation by balloon, 1 or more strictures
45341
Sigmoidoscopy, flexible; with endoscopic ultrasound examination
45342
Sigmoidoscopy, flexible; with transendoscopic ultrasound guided intramural or transmural fine needle aspiration/biopsy(s)
45345
Sigmoidoscopy, flexible; with transendoscopic stent placement (includes predilation)

Emergency vs Critical Care

Emergency Care

Emergency care, with respect to trauma or critical patients, is the recognition of the critical condition, then appropriate stabilization and initial management of these issues. Emergency care gets the patient who is almost dying to 'in critical condition', by correcting the immediate problems, and and managing it.

Emergency care deals with Disaster management (major role) primarily, and have to face a wide variety of patients with varied problems in an uncontrolled environment. Emergency care is confined to short term management of the patient's condition.

Critical Care 

Critical care is the long term management of these patients after they leave the Emergency care.

Critical care takes the patient in critical condition and gets them into stable condition where they can be managed on the general medical floor. They do this by taking hold of certain physiologic parameters and managing it. They also manage the life threatening conditions which take days to treat.

PPOs

Most Americans who have health insurance through their employer (or who are self-insured) are enrolled in some type of a managed care plan - either an HMO or PPO. The most common types of managed care plans are health maintenance organizations (HMOs) and preferred provider organizations (PPOs). Less common are point-of-service (POS) plans that combine the features of an HMO and a PPO.

All managed care plans contract with doctors, hospitals, clinics, and other health care providers such as pharmacies, labs, x-ray centers, and medical equipment vendors. This group of contracted health care providers is known as the health plan's "network."

In some types of managed care plans, you may be required to receive all your health care services from a network provider. In other managed care plans, you may be able to receive care from providers who are not part of the network, but you will pay a larger share of the cost to receive those services. 

Preferred Provider Organizations (PPOs)

A preferred provider organization (PPO) is a health plan that has contracts with a network of "preferred" providers from which you can choose. You do not need to select a PCP and you do not need referrals to see other providers in the network.
If you receive your care from a doctor in the preferred network you will only be responsible for your annual deductable (a feature of some PPOs) and a copayment for your visit. If you get health services from a doctor or hospital that is not in the preferred network (known as going "out-of-network") you will pay a higher amount. And, you will need to pay the doctor directly and file a claim with the PPO to get reimbursed.

Features of PPOs

• You can choose doctors, hospitals, and other providers from the PPO network or from out-of-network. If you choose an out-of-network provider, you most likely will pay more.
• You can receive care from any doctor you choose. But remember, you will pay more if the doctors you choose are not "preferred" providers.
• You do not need a referral to see a specialist. However, some specialists will only see patients who are referred to them by a primary care doctor. And, some PPOs require that you get a prior approval for certain expensive services, such as MRIs.
• If you get your healthcare from a network provider you usually do not need to file a claim. However, if you go out of network for services you may have to pay the provider in full and then file a claim with the PPO to get reimbursed. The money you receive from the PPO will most likely be only part of the bill. You are responsible for any part of the doctor's fee that the PPO does not pay.
• In most PPO networks you will only be responsible for the copayment. Some PPOs do have an annual deductable for any services, in network or out of network.
• If you choose to go outside the PPO network for your care, you will need to pay the provider and then get reimbursed by the PPO. Most likely, you will have to pay an annual deductable and coinsurance. For example, if the out-of-network doctor charged you $100 for a visit, you are responsible for the full amount if you have not met your deductable. If you have met the deductable, the PPO may pay 60%, or $60 and you will pay 40%, or $40.

Billing Process

Tasks in Medical Billing

1. Insurance Verification
2. Patient Demographic Entry
3. CPT & ICD Coding
4. Charge Entry
5. Claim Submission
6. Payment Posting
7. A/R Follow-up
8. Denial management
9. Reporting
   

Insurance verification
Patient provides the insurance details to the Physician's front office. The Physician's front office verifies the patient's insurance details by calling the insurance company or through online verification.

Patient Demographic Entry
The Patient Demographic entry is the process of  capturing all the information of a patient such as his Name, Date of Birth, Sex, SSN, Address, Contact details e.t.c. in the practice management software.

CPT & ICD Coding
The Physician creates the progress note for the Patient encounter. From the progess notes the Coder picks the billable Dx / ICD codes  and the Procedure / CPT codes, in some practices the Physician themselves code the ICD and the CPT codes.

Charge Entry
The Charges are entered into the Practice management software and a Claim is generated.

Claim Submission
Once the Claim is generated the claims have to be sent electronically or thru paper depending upon the insurance company. The claims are checked for errors and then submitted to the clearinghouse for onward submission to the insurance companies.

Payment Posting
The payments received from the insurance companies are posted in the practice management software. The Explanation of Benefits received from the insurance companies are reconciled and the denials are also captured.

A/R Follow-up
The insurance companies are called with respect to each outstanding claim and the reason for the denial of the claims is ascertained.

Denial Management
Depending upon the status of each claim and the type of denial, different denial actions need to be taken to ensure that the claim is paid. Prompt and proper denial management will ensure that the Accounts receivable is under control.

Reporting
AR Reports, Aging reports and Collections reports indicate as to how the Accounts receivable is being managed and how the AR is faring across different collection buckets. The practice generates different reports to keep track of collections, performance and for analysis.