By Isaac Smith, healthcare content strategist, Medcare MSO.
If you are involved in the healthcare industry, you must be familiar with the terms “ASC Coding and Billing” and “Physician Medical Billing.” These two concepts are important to understand if you are a healthcare provider or if you run a healthcare facility. In this article, we will discuss the differences between ASC Coding and Billing and Physician Medical Billing.
Medical billing and coding are critical components of the healthcare industry. They are the processes that ensure that healthcare providers get paid for their services. Medical billing and coding can be complex and challenging, especially if you are not familiar with the terminologies involved. In this article, we will simplify the concepts of ASC Coding and Billing and Physician Medical Billing.
Starting January 1, 2008, the CMS publishes annual updates to the list of procedures an ASC can be paid for. To establish payment indicators and rates for newly created Level II HCPCS and Category III CPT Codes, CMS updates the lists of covered surgical procedures and ancillary services quarterly. ASC billing and coding are explained below.
On the CMS website, you can find the complete lists of ASC-covered surgical procedures and ancillary services, the applicable payment indicators, payment rates before regional wage adjustments, wage-adjusted payment rates, and wage indices.
ASC certification and a CMS agreement are required for this provision. ASCs must accept Medicare’s full payment for ASC services. Physicians and anesthesiologists can bill and be paid for professional services.
Lab services and non-implantable DME can be billed using the correct certified provider/supplier UPIN/NPI. The basics of ambulatory surgery center billing are simple, but physician and facility requirements differ. Physician and facility billing are different from ASC billing. ASC billing and coding don’t focus on a medical specialty like physician medical billing, which must follow a few highly specialized guidelines to get reimbursed.
ASC Coding and Billing
ASC stands for Ambulatory Surgical Center. An ASC is a healthcare facility where surgeries that do not require an overnight stay are performed. ASCs are becoming increasingly popular because they are less expensive and more convenient than traditional hospital settings. ASCs have their own set of codes and regulations that are different from those of physician medical billing.
ASCs are reimbursed for their services based on a fee schedule set by Medicare. The fee schedule is based on the geographic location of the ASC, and the complexity of the surgical procedure. The fee schedule is also updated annually to reflect changes in the costs of providing healthcare services.
ASCs have their own set of codes that are used to bill for their services. These codes are different from those used in physician medical billing. ASC codes are more specific and detailed, as they are designed to describe the unique services provided in the ASC setting.
By Darren Ghanayem and Maria Turner, managing directors, AArete.
America boasts the greatest advancements in medical research in the world: more Americans have received the Nobel Prize in medicine than Europe, Canada, Japan, and Australia combined, which together have twice the American population. America has potential to lead the globe in cutting edge medical care, delivering service that is paid for fairly, accurately, and efficiently. It’s time our payer system caught up with our world-class talent and facilities.
The process of connecting the American healthcare ecosystem’s 3Ps (Payer, Provider, and Patient) has been marred with inefficiencies and inconsistencies. Nowhere is this more evident than in the billing area, where inaccuracies and disputes are commonplace. Resolving these issues is both time consuming and labor intensive—payers often have to jump through hoops to get to the real essence of a provider’s claim and translate accurately the real costs to providers and what to collect from patients. Such billing challenges, or even simple opacity, are not isolated instances—they are embarrassingly prevalent. A 2016 study by the Medical Billing Advocates of America found errors in three out of the four bills they reviewed.
These inefficiencies have added to a fractured, disconnected healthcare ecosystem; patients harbor animosity toward health insurance payers when they are billed more than they expected, while payers and providers are in constant dispute over reimbursement and shared payment arrangements. As a result, the tension can be felt across all constituents.
What’s behind these billing errors? Provider administrators sometimes enter incorrect procedure and diagnostic codes. A simple typo might exponentially increase the cost of the claim. For example, with a single misplaced or misread digit, an X-ray on an ankle might incorrectly register as an image of the blood flow to a brain. Many of these inaccuracies can be attributed to well-meaning human error—and payers need to develop strategies to combat these relatively benign mistakes. They must move forward and work together with providers, because playing the blame game harms every facet of the delicate healthcare ecosystem. But this doesn’t completely rule out the possibility of fraud. In some cases, providers have generated inflated revenue by intentionally using the wrong billing code (a practice commonly called “upcoding”) or incorrectly using modifiers to bypass the review process (e.g., the use of Modifier 59 to report distinct procedural services not normally reported together).
By Christine Cooper, CEO and member; and Jack Towarnicky, member, aequum LLC.
Effective healthcare consumerism requires timely access to accurate provider and hospital fees and estimated out of pocket costs of services – before receiving care. Price transparency puts employer-sponsored benefit plans in the driver’s seat, empowering participants with information that helps them be more prepared, involved and informed in proactively making cost-conscious decisions about their health care options and utilization.
This empowerment is especially important in today’s economy. Many workers are “financially fragile” and have not set aside savings specifically earmarked for out-of-pocket medical expenses, including regular cost sharing – deductibles, copayments, coinsurance. As healthcare continues to see rising cost inflation, price transparency is more in the spotlight, triggering a (re)introduction of healthcare consumer strategies. By taking advantage of price transparency, making comparative cost and quality information available, and capitalizing on cost containment opportunities, plan sponsors and their participants can fully optimize the value of their health benefits plan.
Taking Advantage of Price Transparency
There is complexity in healthcare due to a lack of price transparency. This is especially prevalent in medical billing. Health policy changes have been enacted to make cost information in the healthcare industry more easily available to consumers with the expectation that price transparency will provide better metrics for healthcare spending. The appeal of price transparency is based on the view that increased consumer choice and less information asymmetry will aid in achieving higher-quality, lower-cost health care.
Legislation is now in effect to better enable Americans with knowing the true cost of provider health services before receiving care and submitting a claim. Federal law now supports employer-sponsored health plan access to price transparency with added levels of protection and fairness. Executive Order 13877—Improving Price and Quality Transparency in American Healthcare to Put Patients First, significantly expanded the requirements for hospital and other medical provider price transparency.
Most of the laboratory practitioners lose millions of dollars just because of inefficient management of lab billing services. Usually, it happens because of the lack of a sufficient workforce, equipment required for billing, and more importantly time. If you are finding it difficult to keep your claims process optimized then you must acquire the assistance of professional laboratory billing companies.
A reliable lab billing company stays well-versed with the recent evolutions in the healthcare industry. They provide a dedicated workforce that follows up on all claims. They try to collect maximum revenue for your practice to achieve mutual business success goals.
For this purpose, they implement every preventive measure to submit clean medical claims. When error-free claims are submitted in a timely manner, you can get quick reimbursements. This leads your practice towards long-term financial stability. Moreover, you get complete control of your lab revenue cycle management.
In addition to this, you don’t need to spend your time on hectic and time-consuming consuming tasks of lab billing and coding. Because outsourced billing experts eliminate the responsibility of your laboratory staff. And you can also get rid of the constant monitoring of your staff.
You and your healthcare staff can utilize the saved time in enhancing your patients’ encounters at your lab practice. Sometimes, laboratory practitioners feel hesitation in hiring a third party for their financial management.
If you are one of them, stop thinking like this. Because you don’t lose control over your finances because professional laboratory billing companies keep you updated with regular analytical reports.
Moreover, hiring lab billing agencies can help you to drive maximum profitability to your business in the following ways:
By Devin Partida, technology writer and the editor-in-chief, ReHack.com.
Medical billing records may help create a fuller picture of how the COVID-19 virus has impacted the country.
Researchers have started taking to repositories of claim and billing code data to learn more about patients — who they are, what challenges they faced and how they had to navigate the health care system during a pandemic.
Combined with other data on the financial impact of COVID, this research offers a much clearer view of how the pandemic has impacted patients and strained the American medical system.
1. Chronic Kidney Disease May Be the Most Common COVID-19 Comorbidity
In July, FAIR Health, a provider of health care solutions, released a report on how billing records could reveal more about COVID patients’ stories. Most prior case studies found that type 2 diabetes and hypertension were the most common comorbidities. Respiratory conditions, like asthma, COPD and sleep apnea, along with heart conditions, typically made up the rest of the top 10.
The billing data was mostly in line with these previous findings — but had one key difference. The No. 1 comorbidity was chronic kidney disease and failure, rather than hypertension or diabetes.
The FAIR Health report also diverged from other case studies in finding that anxiety was one of the top 10 comorbidities, coming in at ninth place.
Almost a year into the COVID-19 pandemic, the stress surrounding the rising number of cases and the ensuing economic recession reminds high. Nearly half a million Americans have been hospitalized due to coronavirus, putting untold stress on patients, their families and hospital staff. Healthcare and health insurance costs are likely to rise after an unprecedented year, while millions struggle to meet their basic needs.
On top of that, surprise medical billing can quickly spiral into large amounts of debt and even bankruptcy. Routine tests alone can result in thousands of dollars in uncovered charges; some hospitalized patients have received bills upward of $400,000. While the situation absolutely harms patients, it also negatively impacts health providers, insurers and the industry at large.
Just as we’ve reevaluated the way we conduct nearly every aspect of daily life, we’ve also had to take a hard look at whether our healthcare systems are actually working. In order to make informed decisions about their physical and financial health, consumers need greater transparency throughout the healthcare experience.
After years of mounting demand for a better consumer experience in healthcare, we’ve reached a tipping point. Transparency is no longer optional.
Patients need to choose providers based on quality and cost
Consumers have long been frustrated with the status quo because it doesn’t provide them with a source of truth about healthcare costs and healthcare quality. It’s baffling that healthcare is the only consumer experience that doesn’t encourage shopping for the best option at the best price. We have a suite of easily available tools to help us shop for most items, evaluate their quality and compare price. Why isn’t our healthcare—which is much more important than the latest gadget—the same?
For example, even when patients know to search for an in-network provider, they struggle to select the right one. Many insurance carriers have some aspect of price or force ranking of providers on the ‘Find a Provider’ section of their website—but these aren’t exactly intuitive user experiences (perhaps by design).
The rise of this decade has brought new and complicated challenges that are accompanied by some other problems that left unresolved during the last decade. 2020 has come up with some unprecedented and unpredictable host of challenges such as global medical emergency because of the vast exposure of COVID-19 making its way from China to the US in a few days.
This global crisis has thrust upon a lot of burden on the medical practitioners, especially on physicians. In a physician’s office or any healthcare center, it has increased burden on both front-end and back-end departments of the healthcare centers and both seem to be in turmoil in such circumstances. Along, with these challenges physicians have to also suffer from the financial crisis due to changing rules and policies for physician billing services. It is the hardest challenge for physicians to align their financial policies with respect to the real-time changes in medical coding and physician medical billing services.
In this article, I have mentioned the following top 10 challenges for physician billing services that are quite difficult to encounter;
Excessive Administrative Burden
It has always been a cumbersome task for the physicians to handle the burden of excessive stress of managing both patients and physician medical billing services. This is not a new issue and physicians have been facing this issue all around America for decades. No matter their association with the private or public practice, no matter if they are practicing individually or on a large-scale healthcare center, they have to improvise administrative responsibilities.
Medical billing is process of handling and managing claims, processing payments, and generating revenue. It entails various tasks – coding claims correctly, tracing them, following up and much more.
The medical billing task is challenging and demanding too. But, it can be made easy by integrating the billing system with an EHR software.
Let’s have a look at the integrated electronic health records benefits in medical billing process.
When the billing process is integrated with an EHR, it becomes a comprehensive platform. You don’t need to input the data manually and repeatedly.
The integrated system also removes the need to fax or photocopy every billing sheet. This not only saves time and boosts productivity, but also minimizes human error during data transfer, saves paper and money.
EHR becomes a comprehensive platform to perform a number of activities. Accessing data from a single place makes your process highly cost-effective and accurate.
Build trustworthy relationships
Integrating your EHR and the billing system brings in transparency in the medical billing process. The EHR software seamlessly integrates with billing system to submit cleaner claims and schedule appointments more easily.