|Type of paper:||Essay|
|Categories:||Medicine Healthcare policy Customer service|
Registration of patients is a major component of a physician's medical billing since a patient should efficiently register for a doctor's visit when he/she is called for a setup with a healthcare provider. The patient's information should exist in the file if he/she had a visit before, and therefore the patient should only provide the reason for the visit. But new patients should give both insurance and personal information to receive services (Kaniadakis, 2014).
Confirm Financial Responsibility
Financial responsibility helps in determining what the patient owns after visiting the doctor, and the moment the biller has all the information from the patient, he/she is ready to determine what service is to be provided based on the patient's insurance plan.
Patient Check-In and Check-Out
The patient is required to complete some forms on their arrivals, but a regular or previous patient can only confirm their information available with the doctor. Again when the patient is checking out, a report is taken to the medical coder to translate and abstract the information into accurate medical code.
More importantly, the biller transfers the super-bill from the medical coder into either the billing software or paper claim. That will include the cost of such procedures found in the paper claim, and the amount of money that should be paid will be sent to the payer. The biller will then ensure that the claim conforms to the compliance standards.
According to the Health Insurance Portability and Accountability Act, health organizations should electronically submit claims provided the Act covers them unless specific situations do not allow them (Kaniadakis, 2014). Additionally, the Act does not demand electronic transactions only, except those that are covered by HIPAA requirements.
The claim takes the process of adjudication after reaching the payer, where the payer has to evaluate the claim and make a decision in the validity of the claim and the amount to reimburse the provider. More importantly, the stage of adjudication is where the claim can be rejected or accepted.
General Patient Statements
When the report has been received from the payer, the biller then makes the patient's statement. The statement becomes the bill from the processes and the services received from the health provider. Finally, if the payer conforms to the payment for the health services provided, the remaining balance is given to the patient.
Follow-Up on Patient Payment and Collection
The final component in the billing process is performing a follow-up on the payment and collection through ensuring that the bills are well paid. The billers ensure constant accuracy for the medical billing, timely mailing, and follow-up of the payment with the patient.
Inpatient and Outpatient Hospital Billing
Hospital billing is a more complex process because of the complication of the hospital environment. It is more challenging to ensure that the medical billing is properly done and successfully reimbursed the claims at the right time. More imperatively, the outpatient is those that check into the ER and receives medication without being admitted to the hospital for some days, released with twenty-four hours, while the inpatient is admitted for an extended number of days. Inpatient medical billing involves billing for a day visit, while outpatient involves billing for an extended stay in hospital (Kaniadakis, 2014). Additionally, inpatient coding is based on the ICD-9/10-CM treatment processes for billing and effective reimbursement. However, the procedures for the treatment of the outpatient remain the same, but the reimbursement depends on the codes assigned from Health Common Procedure Coding and Current Procedural Terminology. Again the reimbursement technique that is used by the government programs and health care providers in reimbursement for inpatient hospitalization is called Inpatient Prospective Payment System. In contrast, that of outpatient hospitalization is called Outpatient Prospective Payment System.
UB-04 Hospitalization Claim Form
The UB-04 claim form is a standard billing form that is used by any health organization for medical billing purposes, as well as mental illness claims. Notably, the form is developed by the Medicaid and the Center for Medicare, and it is printed in on a white paper with red ink. It is worth noting that the American Hospital Association and the National Uniform billing Committee are the bodies that design and modify UB-04 electronic data, and publish it manually (Kaniadakis, 2014).
Medicare Schedules and Provider Reimbursement
Medicare fee schedule comprises a list of fees that are used in paying doctors and other healthcare providers. The comprehensive fee list is utilized in reimbursing health providers a fee based on their services. The Center for Medicare Service designs the fee schedules for the doctors, clinical laboratory services, and ambulance services, as well as the medical equipment and the supplies. Also, provider reimbursement explains the payment received by the hospital, facility, doctor, or any other healthcare provider for the delivery of their services. More importantly, health insurer often covers a portion of the healthcare cost or the whole cost of healthcare.
Medicare Fraud and Abuse
More significantly, Medicare fraud leads to improper payments, and it is intentionally done, which may cause erroneous billing leading to overpayment for medical care. The fraud is beyond false claims or misrepresentation to achieve false payment, but it can happen in any institution, including large and solo practice institutions (DiSantostefano, 2013). Additionally, the fraud may be committed by different people, including physicians and the patients, and may include; billing for non-provided services, up-coding, billing for unnecessary items, and billing for failed appointments. Besides, Medicare abuse may involve practices that indirectly or directly lead to unwanted costs for Medicare programs. Similarly, payments from erroneous billing may happen in different forms, including insufficient documentation involving treatment plans and progress notes.
Medicaid Eligibility and Benefits
Affordable Healthcare Act developed a method of determining the eligibility for the Medicaid programs. Some people are exempted from the Modified Adjusted Gross Income-based income, which includes disability, blindness, and aged-based eligibility individuals (Centers for Medicare & Medicaid Services, 2013). The Supplemental Security Income program is used in determining the medical eligibility of older adults, the blind, and people with disabilities. Some eligibility does not need income determination from the Medicaid agency, such as children with an effective adoption assistance agreement. The young adults are also eligible for any level of income.
Process of Submitting Medicaid Claim
The process of submitting Medicaid claims includes meeting the filing deadlines in which the claim is submitted to the Medicaid if the healthcare provider is not expected in the program. The deadline for submission of claims may vary with the state. The next process involves requesting a claim form in which the patient should visit a local Medicaid in seeking for a claim form to complete, and then completing the claim form properly because the Medicaid demands full information to process the claims form (Centers for Medicare & Medicaid Services, 2013). Again the form requires the patient to provide the necessary information, including dates and the onset of the sickness. Finally, the process involves choosing a claim submission option such as through mailing or sending through fax based on each state's method of submission.
Centers for Medicare & Medicaid Services (CMS), HHS. (2013). Medicaid and Children's Health Insurance Programs: essential health benefits in alternative benefit plans, eligibility notices, fair hearing and appeal processes, and premiums and cost-sharing; exchanges: eligibility and enrollment. Final rule. Federal register, 78(135), 42159.
DiSantostefano, J. (2013). Medicare fraud and abuse issues. The Journal for Nurse Practitioners, 9(1), 61-63.
Kaniadakis, S. J. (2014). U.S. Patent No. 8,666,772. Washington, DC: U.S. Patent and Trademark Office.
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