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Medical Billing Insights – Interview with ABA Billing Service

Medical Billing Insights – Interview with ABA Billing Service

Are you working in the medical billing industry as a biller or an owner of a billing company? If so, the KEY medical billing insights and best practices that came out of our interview with Maura Jansen (VP of Operations) and Jennifer Withington (Director of Revenue) at Missing Piece Billing & Consulting Solutions will be VERY VALUABLE for you to consider.

Jennifer, an expert in understanding the problem-solving techniques and the investigative nature of medical billing, offers insights that both educate and inspire. Maura, an executive member of the billing community, also added an important perspective about EZClaim’s medical billing software. The following are some highlights from our interview.

EZCLAIM: When did you get into the industry?
JENNIFER
: “I worked in group homes for the waiver side of group aid and then I went to Missing Piece. Missing Piece primarily deals with ABA providers and provides early intervention rendered to children. For me, the move from waivers with adults to professional billing, indirectly assisting children, was attractive and I took to the billing side of things.”

EZCLAIM: What does that mean when you say you took to the billing side of things?
JENNIFER
: “Insurance doesn’t make a lot of sense when you first start. So, I took to the investigative side of making sense of medical billing claims. Figuring out what the payer’s rules are, reading their manuals, and figuring out the technical jargon with the purpose of preventing claim denials was attractive. I liked the puzzle of it.”

EZCLAIM: Are there things that you value in your work that offer meaning to what you do?
JENNIFER
: “It’s really when I know that if I do not intercede with the insurance company and get this paid the patient is going to be responsible for the balance. So, to help, I have taken things to the department of insurance, or I have gone ahead and filed that third letter of appeal and really taken the time to research it. Because I don’t want a parent who is already struggling with having a child with more needs than maybe the other children would have, I don’t want them struggling with a $25,000 bill. ABA is extremely expensive because it works. And so, if insurance doesn’t pay it then the only other funder is the parent. And my goal is that parents should not have to pay any more than they absolutely have to.”

EZCLAIM: What are some of the strengths that make you good at what you do?
JENNIFER
: “I am a good problem solver. I am good at taking a large problem and breaking it into smaller problems and knocking each one down until I solve the bigger issue. At the end of the day, that’s really what accounts receivable is.”

EZCLAIM: What would be an example of your problem solving on a day-to-day basis?
JENNIFER
: “So you always start with the denial and then you have to work back to the billing. For example, if I have a claim denied for services rendered from an out-of-network service provider, but we know we are in-network then my first problem is, are we actually in-network? Then, you go onto the next link which is did the payer recognize you as in-network? It becomes like a decision tree, if you get a ‘yes’ then you are probably done, and you get the claim processed. If it is ‘no’, then you have to start digging with the payers contacting reps, make calls, and supply them with documents to get down to why they don’t have your provider listed within the network. Once you solve that problem, then the claim should be able to be processed. It is either going to pay or deny. Then depending on which one it is, you apply the same technique.”

EZCLAIM: What would you offer someone who is considering entering the field?
JENNIFER
: “You should be good at processing and reading information because to get a claim paid you to have to know the rules of engagement. You need to be familiar with how to read a contract, how to read technical information about billing, and have to have a glossary of information about what you are billing. Those are the building blocks to get to know what you are doing.”

EZCLAIM: You work with EZClaim’s medical billing software platform, what role does their software providers and how does that impact your work?
JENNIFER
: “EZClaim really serves to eliminate these denials before they happen, which is the ultimate goal of any accounts receivable or billing. EZClaim has edits that we use. It alerts us if the system thinks the claim is a duplicate, for example. It also helps in the set-up of the claim. We load all the fee schedules in EZClaim’s procedure code library and that lets us monitor the charge rate, make sure all the points of billing are on the claim (i.e. correct code, modifier, and charge). They also make sure that the authorization is appended to the claim. And then after we have actually done the work of getting a claim in the system, we use EZClaim reports to audit our own billing. So, we use the EZClaim service report. It makes it easier for us and our providers to see what has been billed and make sure that the billing is correct.”

EZCLAIM: If you were going to share something with your colleagues in the field, what would you share about the software that makes your life easier?
JENNIFER
: “Number one, it is not the software itself, it’s the EZClaim staff.  Their customer service is far beyond what a normal billing software company provides. If I have a problem, or if I have a report, or if I have a data point that isn’t in any report, they are available and they are there for me. And if they don’t have a solution for the problem, they will provide me with a workaround. So, that is very valuable. That is why Missing Piece works so well with EZClaim because customer service is number one for us, too. They don’t just want to answer your question, they want to help you understand your question.”

“The other thing that I find valuable is that their reporting modules are just a lot more robust than the other billing software companies that I have dealt with.”

EZCLAIM: Maura, do you have any thoughts from an administrative level that you can offer on EZClaim?
MAURA
: “Well, when we hire a new person we know that, even if this person has very little experience in the healthcare field, it’s going to be a quick and easy process for them to learn EZClaim… EZClaim has also made it kind of a joy to work with. We really value them as a partner. We love the service they provide, and we value them as a platform.”

ABOUT EZCLAIM:
EZClaim can also help you with medical billing insights since it is a medical billing and scheduling software company. It provides a best-in-class product, with correspondingly exceptional service and support. Combined, they help improve medical billing revenues. To learn more, visit EZClaim’s website, email them, or call them today at 877.650.0904.

Life Cycle of a Medical Bill (Revenue Cycle 101)

Life Cycle of a Medical Bill (Revenue Cycle 101)

Life Cycle of a Medical BillThere are five ‘phases’ in the life cycle of a medical bill: Pre-appointment; Point of care; Claim submission; Insurance payment or denial; and Patient payment. This post will overview each of these phases, and could even be considered to be a “101-level” course on Revenue Cycle Management.

With high deductible health plans on the rise, the recent explosion of telehealth appointments due to COVID-19, and many other factors in play, it’s more important than ever for everyone to understand the life cycle of a medical bill, and how the process works. The healthcare revenue cycle is relevant not only to those who work in healthcare, but to the patient, too.

The revenue cycle is the series of processes around healthcare payments—from the time a patient makes an appointment to the time a provider is paid—and everything in between. One way to think of it is in terms of the life cycle of a medical bill. Although there are many ways this process can play out, this post will lay out a common example below:

1. Pre-appointment
For most general care, the first stage of the revenue cycle begins when a patient contacts a provider to set up their appointment. Generally this is when relevant patient information will begin to be collected for the eventual bill, referred to on the financial side of healthcare as a claim.

At this point a provider will determine whether the appointment and procedure will need prior authorization from an insurance company (referred to as the payer). Also, the electronic health record (EHR) used to help generate the claim is created, and will begin to accumulate further detail as the provider sends an eligibility inquiry to check into the patient’s insurance coverage.

2. Point of care
The next step in the process begins when the patient arrives for their appointment. This could include when a patient arrives for an initial consultation, an outpatient procedure, or for a follow-up exam. This could also include a Telehealth appointment.

At any of these events, the provider may charge an up-front cost. One example of this is a co-pay, which is the set amount patients pay after their deductible (if they are insured), however, there are other kinds of payments that fall into this category, too.

3. Claim submission
After the point of care, the provider completes and submits a claim with the appropriate codes to the payer. In order to accomplish that, billing staff must collect all necessary documentation and attach it to the claim. After submitting the claim to the payer, the provider’s team will monitor whether a claim has been been accepted, rejected, or denied.

[ Note: Medical coding refers to the clerical process of translating steps in the patient experience with reference numbers. The codes are normally based on medical documentation, such as a doctor’s notes or laboratory results. These explain to a payer how a patient was diagnosed and treated, and why. This information helps the payer decide how much of an encounter is covered under any given insurance plan, and therefore how much the payer will pay. ]

4. Insurance payment or denial
Once the payer receives the claim, they ensure it contains complete information and agrees with provider and patient records. If there is an error, the claim will be rejected outright and the provider will have to submit a corrected claim.

The payer then begins the review process, referred to as adjudication. Payers evaluate claims for accurate coding and documentation, medical necessity, appropriate authorization, and more. Through this process, the payer decides their financial obligation. Any factor could cause the payer to deny the claim.

If the claim is approved, the payer submits payment to the provider with information explaining details of their decision. If the claim is denied, the provider will need to determine if the original needs to be corrected, or if it makes more sense to appeal the payer’s decision.

Following adjudication, the payer will send an explanation of benefits (EOB) to the patient. This EOB will provide a breakdown of how the patient’s coverage matched up to the charges attached to their care. It is not a billing statement, but it does show what the provider charged the payer, what portion insurance covers, and how much the patient is responsible for.

5. Patient payment
The next phase occurs when the provider sends the patient a statement for their portion of financial responsibility. This stage occurs once the provider and payer have agreed on the details of the claim, what has been paid, and what is still owed.

The last step occurs when a patient pays the balance that they owe the provider for their care. Depending on the amount, the patient may be able pay it all at once, or they might need to work with the provider on a payment plan.

 

The above example represents one way the lie cycle of a medical bill can play out. Some of the ‘phases’ are often repeated. Because of the complexity of healthcare payments and the parties involved, there is not always a ‘straight line’ from patient care to complete payment. That’s why we call it the revenue cycle, and there are companies that provide systems for its management.

One of EZClaim’s partners, Waystar, aims to simplify and unify healthcare payments. Their technology automates many parts of the billing process laid out above, so it takes less time and energy for providers and their teams, and is more transparent for patients (Click here to learn more about how Waystar automates manual tasks and streamlines workflows.) When the revenue cycle is operating at its most efficient, providers can focus their resources on improving patient care—and that’s a better way forward for everyone!

For more information of how Waystar works together with EZClaim, click here.

[ Article and image provided by Waystar ]

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ABOUT EZCLAIM:
EZClaim is a medical billing and scheduling software company that provides a best-in-class product, with correspondingly exceptional service and support, and can help improve medical billing revenues. To learn more, visit their website, e-mail them at sales@ezclaim.com, or call a representative today at 877.650.0904.