DAY 1 LEARNING POINTS
Day 1 Training:
Our Training Agenda
1. Healthcare System in US Overview
2. What is Medical Billing?
3. Insurance Providers & Insurance Types
4. What is the Credentialing Process?
5. Popular Abbreviations
1. Healthcare System in US:
There is no universal healthcare. The U.S. government does not provide
health benefits to citizens or visitors. Any time you get medical care,
someone has to pay for it.
Healthcare is very expensive. According to a U.S. government website, if
you break your leg, you could end up with a bill for $7,500. If you need to
stay in the hospital for three days, it would probably cost about $30,000.
Most people in the U.S. have health insurance. Health insurance protects
you from owing a lot of money to doctors or hospitals if you get sick or
hurt. To get health insurance, you need to make regular payments (called
“premiums”) to a health insurance company. In exchange, the company
agrees to pay some, or all, of your medical bills. Learn more about health
insurance.
A health care provider is an individual health professional or a health facility
organization licensed to provide health care diagnosis and treatment services including
medication, surgery and medical devices. Health care providers often receive payments
for their services rendered from health insurance providers.
2. What is Medical Billing?
Medical billing is the process of submitting and following up on claims with health
insurance companies to receive payment for services provided by a healthcare provider.
It involves translating healthcare services, procedures, and diagnoses into standardized
codes (like CPT, ICD-10, and HCPCS codes) and then submitting these claims to insurance
companies.
Here’s a breakdown of the process:
Patient Registration: Collecting and verifying patient information, including
insurance details.
Insurance Verification: Confirming the patient’s insurance coverage and
determining what services are covered.
Coding: Translating the services provided (such as doctor visits, procedures, or
treatments) into standardized codes that insurance companies recognize.
Charge Entry: Entering the appropriate charges based on the coded information.
Claim Submission: Sending the claim to the insurance company electronically or
on paper.
Payment Posting: Once the claim is processed, payments from the insurance
company are posted to the patient’s account.
Denial Management: Handling rejected or denied claims by addressing the
reasons for denial, resubmitting claims, or appealing the decision.
Patient Billing: After insurance pays its portion, any remaining balance is billed to
the patient.
Follow-Up: Ensuring that payments are received in a timely manner and
addressing any discrepancies.
Medical billing is a critical aspect of the healthcare revenue cycle, ensuring that
healthcare providers are compensated for their services.
3. Insurance Providers:
Health insurance protects you from owing a lot of money to doctors or hospitals if you
get sick or hurt and need medical care. Health insurance can also help you pay for
regular check-ups, laboratory tests, vaccines, and prescription medication.
To get health insurance, you need to choose a health insurance plan, sign up, and then
make regular payments (called “premiums”) to a health insurance company. As long as
you remain eligible and keep paying your premiums, you will be “covered.” This means
that the health insurance company agrees to pay for part of your medical bills.
Two Types of Insurances
1. Federal Insurances
2. Commercial/Private Insurances
Federal Insurances:
These are Government owned Insurances and the two most popular ones are Medicare
and Medicaid. Other examples are Tricare, ChampVA, Children Health Insurance Plan
(CHIP) etc.
Medicare is a medical insurance program for people over 65 and younger
disabled people and dialysis patients.
Medicaid is an assistance program for low-income patients' medical expenses.
Commercial/Private Insurances:
These are privately owned insurances. It covers nearly two-third of America Population.
There are more than 5500+ commercial/private insurance companies around the USA.
Examples of Commercial Insurances are Aetna, Humana, BCBS, UHC and Molina
Healthcare etc
What is Panel:
An insurance panel is a collection of healthcare providers to whom an insurance
company will pay for services for their customers.
3. What is Credentialing?
Credentialing in medical billing is the process that all healthcare service providers
perform to become enlisted with insurance companies.
Upon successful credentialing in medical billing, the healthcare provider is part of an
insurer’s network of hospitals, care providers, health centers, clinics, or medical centers.
After successfully applying and receiving the credential as a listed service provider, a
healthcare operator can receive reimbursements. The reimbursements are received
from the insurer.
The insurer pays the healthcare operator for the services rendered to their customers
by the healthcare operator. The agreement terms between the insurer and healthcare
service provider are a contracting or credentialing agreement.
How to check if the panel is open or not on a complex panel?
We should have to call or email the respective insurance payer addressing our concern,
but before this we should have the basic information of the provider or group for which
we are checking the panel status.
Popular Abbreviations
Medical Doctors/Facilities/Clinics
Providers
CPT Code Current Procedure Terminology. These are Treatment Codes
EOB Explanation of benefits
ICD International classification of diseases. J45. 0 – J45. 998 is for
Asthma Example
EDI Electronic Data Interchange
TIN Tax Identification Number
NPI National Provider Identifier
ADA American Disability Act
SSN Social Security Number
EFT Electronic Funds Transfer
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