Basics of Medical Billing Compliance Plan

Medical billing is the process of submitting the medical bills of a patient by a hospital to the patient’s insurance service provider. For example, most individuals are covered under some kind of a medical health insurance policy. This could either be State or some third party insurance coverage, but the process remains similar. Normally when a patient visits a hospital, his/her entire health related information is collected and this becomes the person’s health record. This record is treated with utmost confidentiality and remains with the hospital. When a bill is raised for a medical treatment, the bill gets coded. The codes for various ailments and diseases are grouped in the CPT manual (Current Procedural Terminology).

Medical Billing can be done both physically and online using the code submitted, which is manually or electronically verified against the patient’s medical records to determine whether the diagnosis is accurate, whether the person was covered by insurance at the time of the ailment. Once all the information is confirmed, the bill is sent to the insurance company which verifies and either pays or rejects a claim depending on various factors including accuracy of information, policy coverage etc.

Most often physicians and doctors have enough on their plates attending to patients. It is not easy to pause during a treatment to write down codes describing the medical ailment of a patient. But unfortunately, to submit the bill for payment, the code becomes necessary. Therefore, the medical personnel who are preparing the bill for submission to the insurance company should be familiar with various codes which describe the ailments as grouped under CPT. This is not easy and the flip side is wrong coding which can only result in more work as the claim is returned for inadequate or wrong information. Medical compliance is, therefore, a means to ensure that the patient’s record is coded accurately to ensure quick clearance.

What also happens is that the business of medical billing, like all other systems is not outside the scope of fraudulence. Frauds to the effect of wrong data, duplicate billing and inaccurate records are only some of the types of frauds which can be used to make money. Fraud is treated extremely strictly with cases attracting fines in the range of US$250,000. Therefore, it is important to understand and adhere to medical compliance programs. But for this, it is necessary for the medical coder to be absolutely familiar with ailment codes.

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