Many practices in the US continue to use paper based methods for billing their patients and filing for claims even though their other management areas are electronic or cloud based. The case might be because of complicated medical billing process and too many components to handle. This article offers a lean solution for practice management systems to build tech enabled billing system for the benefit of their partnering practices.
a) Raising invoices for patients to make payments directly
b) Filing claims for insurance providers.
Invoicing, Electronic filing, Clearinghouse integration, and Payment gateway
This connects the different entities such as patient, practice, clearinghouse involved in the billing process. At this stage, it is alright to not connect the insurance providers directly into your PMS as clearinghouse integration will be good enough.
How it works
Once the core elements are in place for a lean system, more comprehensive system can be built in later stages. Based on the medical billing process more features will make the billing procedure more robust.
How it works
An initial bill estimate to be presented to the patient based on the diagnoses. Patient can choose which all treatments to go for. And invoice can be generated after the patient confirms, in case they are paying out of pocket.
Benefit: An early confirmation from the patients helps in getting payments more successfully.
Invoices for the deductibles and co-payments to be raised for the patients, based on their insurance plans and coverage.
The billing section in practice management systems will import the billings codes and other treatment information to initiate claims filing. It will track the paid treatments and practices can view the claims status here.
Parallel to ANSI 837 format, claim filing to be done directly to Medicaid or Medicare using CSM-1500 format. Practices can upload a scan of the hard copy for this or send information electronically.
Once the payment is collected a confirmation should be sent to patients about the successful claims procedure.
Scanning hard copy for CMS-1500
Hard copy format of CSM-1500
From the many options, Apex EDI stood out because of its cost, features, and the integration with the PMS so that the practices will not have to leave their PMS to process claims.
Navicure, Apex EDI and Claim MD are one of the best clearinghouses in market. They all provide ERAs and EOBs, allow corrections and resubmission of claims in real time, claims history and electronic filing.
Though clearinghouses ensure insurance requirements and HIPAA compliance which reduce the potential for error dramatically, PMS can file the claims directly to insurance providers (I’ll be writing more on this).
A PMS can allow their practices with greater technological capability in carrying out medical procedures to save costs and effort on external billing methods. With a lean system, PMS can build the billing system faster and much closer to the needs of the practices.