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Friday, October 10, 2008

How it Works: Getting Paid That Is.

When you go to a restaurant, you order the food, eat, the bill comes, and you pay for the meal either with cash or credit card.  If you use an accountant, they do their work, send you a bill, and you send them a check.  If you purchase a sweater on-line,  you supply the merchant with your credit card or paypal information, hit submit, and then the merchant processes the order.  In general, the process is pretty straightforward and transparent.

In most medical practices, the process is much more complex, less transparent, and more open to error.

In medical practice, from the instant a patient calls to make an appointment, a cascade of events gets initiated that results several weeks to several months later in a payment into your bank account. 

Here's the steps that follow the "I'd like to make an appointment with Dr Schoor" phone call:

1st: Insurance: yes or no
  • No: Straightforward fee for service, just like restaurant
2nd: Yes, Insurance
  1. Determine type
  2. Referral needed
  3. Verify eligibility
  4. Give appointment
3rd: Patient in office
  1. Obtain insurance ID card
  2. Determine copay amount
  3. Determine method of payment, ie cash (great), cc (OK), check (risk of bounce)
  4. Give receipt
  5. Room patient
4th: After physician sees patient
  1. Determine diagnosis codes (ICD9)
  2. Determine procedure codes (CPT)
  3. Determine level of visit (1-5)
  4. Manually or automatically via EMR/PM charges and codes are sent to biller/billing software
5th Billing
  1. ICD9 and CPT codes are entered (manually or via computer) and a claim is generated
  2. Claim is edited either manually or via PM program to make sure that all demographics are correct, NPIs are correct, PTANS of present, if needed, and ICD9 and CPTs match, and more.
  3. Claim is then either printed on a HICFA 1500 form and mailed directly to insurance company or submitted electronically to a clearinghouse (middle man)
  4. Clearinghouse adjuticates claims (further processing for all above) and then either rejects claim or forwards it onto the pertinent insurance company either electronically or on paper.
  5. Insurance companies review claims and either: authorizes claim "as is" and remits check for contracted amount, down codes encounter and remits check for lesser amount, or does nothing (which then requires you to track down the claim).
6th Payment
  1. Payment comes in the form of an EOB, or explanantion of benefits and a check.
  2. Checks can either be attached to the EOB (paper) or issued via ETF (electronic transfer of funds).
  3. Check amount must be verifed against EOB.
  4. Practice can then either accept payment "as is" or re-submit claim with a dispute.
And that is for a simple office visit.  The process varies a bit for things like hospital consults and procedures or for procedures performed in any out-of-office setting.  In addition, each payer and each plan, within the plan, within the plan, has slightly different rules, policies, and procedures, and these can muck up the reimbursement's timeliness and accuracy for the doctor. 

And what about copays?  I have not even dealt much with this easiest part of the whole thing, that is the copay.  Some people have them and some don't.  Some plans have a flat copay amount for all visits, while others have different amounts depending on the type of visit, e.g. primary care, specialist, ER, hospital, lab, etc.  To make everything even more complex, not all ID cards indicate the copay that fits the particular situation.  In this last instance, the only way to know the copay amount is get it off the EOB in the box that reads "patient responsibility."  Then you must, contractually, go after the patient.

Going after the patient, for even as little as $3, is not always easy.  Even though the majority just pay with no fuss, some patients get very upset at receiving a bill for any amount.  For all patients, the practice must send statements, ie bills, and this costs 41 cents, plus envelope, per bill plus staff time for each patient per statement period.  When the patients return their payments, the cycle is complete. . .unless they have secondary insurance. 

And that is a whole other discussion.