Medical Claims Processing Software

Submitting a healthcare claim requires medical claims processing software. It is often difficult to work with large insurance companies to receive proper payment for services rendered to patients and clients. Not only is there a lot of bureaucracy involved, governmental regulations, differences in billing procedures and statutes of limitations all complicate the process. A reliable, knowledgeable employee, using a sound medical insurance billing software program is a physician's, hospital's, or clinic's first line of defense in successfully garnering payment for healthcare services performed. The software available is systematic in the way claims are entered into the computer. Medical claims processing software also keeps meticulous records in a database and prints out a paper copy for filing. Luckily, the protocol for submitting invoices is the same whether or not the insurance company is privately owned or governmentally run.

The process of filing is the paper "interaction" between an insurance company and the original healthcare provider. The initial visit begins this interaction. Usually, a physician will request a new patient's insurance information or an existing patient's information if he has changes healthcare coverages, companies or plans. This information is kept in the patient's file. Healthcare files contain all the patient's history of treatment and diagnosis. Eventually, this will become crucial in determining if the individual had a preexisting illness that led to the office visit, or if this was the initial occurrence of the injury or sickness. Information of this nature is needed, as many healthcare claim representatives allot a different amount of coverage and allowable expenses for preexisting conditions versus initial occurrences. Using the patient's testimony of the present symptoms, personal health history and clinical testing if needed, the physician will then determine the correct level of care and service to provide.

Determining the correct level of service and care to provide to the patient is also vital, because the bill will only be paid if the physician decides correctly on the allowable care. If a diagnosis is unable to be determined, the symptoms will be recorded for payment purposes. Once the correct level of service is determined, the physician then administers the necessary medicine or treatment. The level of service is translated into Current Procedural Terminology. The CPT is always five digits long. The healthcare professional's verbal diagnosis of the patient is also translated into a numerical code. The numerical code for the verbal diagnosis is determined through consulting a database called, ICD-9-CM. Both the CPT and the ICD-9-CM are vital in submitting a bill for payment.

After translating the diagnosis and treatment into numeric codes, the medical insurance billing software will then transmit a bill electronically either directly to the insurance company (payer) or to a clearinghouse that processes invoices for numerous healthy indemnity companies. For years, the bills were sent on a paper form called CMS-1500. Many small medical offices still transmit bill information on CMS-1500 forms. In the event that a medical practice is still sending paper invoices, medical claims processing software still produces the paper bills.

The payer then employs healthcare specialist to review the electronic bill or the CMS-1500 form produced by the medical insurance billing software. The specialist reviews the invoice, considering the patient's history, patient's eligibility, provider's credentials and medical necessity. After review, the payer either accepts or rejects the claim. If the bill is accepted, the payer agrees to pay a predetermined percentage of the services rendered by the healthcare professional. If the bill is rejected, it is then sent back to the healthcare professional with an explanation of why it was denied. The healthcare provider will then look at the rejection notice, reconcile it with the original bill, make requested changes and resubmit it to the payer. The invoice then goes through the review process again. This cycle of denial and revision can continue until the payer agrees to pay the agreed upon percentage of the original bill, or the healthcare professional gives up and accepts only partial payment by the health indemnity company. Rejections, denials and overpayments can be quite common. Sometimes up to 50% of invoices are rejected. The complexity of claim format is usually blamed for high failure rate. Again, the advances being made in medical insurance billing software is taking the guess work out of medical bills and enabling healthcare providers to submit correctly the first time.

Health Insurance Portability and Accountability Act (HIPAA) protects the information in patient's files. HIPAA urges healthcare professionals to file claims electronically in compliance with their regulations. The regulatory body of the Health Insurance Portability and Accountability Act houses a database that can be referenced even before services are performed. In this way, a physician can check a patient's eligibility before prescribing medication or initiating treatment. They were now required to submit all large financial activities electronically to a centralized HIPAA approved system. As a result of some of the newer HIPAA regulations, healthcare professionals had to upgrade their medical claims processing software. Though this was a small price to pay for increased efficiency, patient protection and fewer rejected invoices. Receiving payment for services rendered, invoicing correctly and determining patient eligibility is by no means simple, but with the advancements in medical insurance billing software, it is getting easier and easier to go to the doctor, file a bill and focus on recovering. "When Jesus heard it, he saith unto them, They that are whole have no need of the physician, but they that are sick: I came not to call the righteous, but sinners to repentance." (Mark 2:17)

Medical Billing Software

Medical billing software can be used for a small office, group practice, or as third party billing, including a variety of features that make billing for several different companies easy and efficient. Some companies online offer software access for a monthly service fee and do not require a long term contract. Take advantage of offers from software companies to use a demo version for a trial period before making a purchase. Web-based packages will provide upgrades, backups, troubleshooting, technical support, and provide the flexibility of accessing their program from any computer with an Internet connection. Medical office management software is ideal for health care providers or administrators who want to reduce costs and use one program for all office functions, including billing, word processing, financial reporting, and accessing a large patient database. Some other available features might include tracking for specific procedures or scheduling for specific appointments.

Web-based programs provide some key benefits for users, including security and encryption, easy access, information backups, ongoing technical support, and up to date information. Medical billing software available online, offers some choices that sound enticing to individuals who are limited due to a strict budget. Reducing costs is possible by using Web-based options by eliminating costs for licenses, multiple users, hardware upgrades, additional purchases for ongoing support, and backup tapes. Looking at the needs of the company or individual is necessary to help determine what type of program is best. Do some research online and see what is available before making a purchase. Using a Web-based service might prove to be easier, less expensive, and less problematic than purchasing a program that requires licensing, multiple users, and ongoing tech support. Services online usually charge a monthly service fee and is not limited to users, or practice size.

Managing a medical office can be a big job when considering all of the details that must be kept up with on patients and employees. Medical office management software can turn this big job into a manageable one because of the variables that are offered. Packages should include patient information and appointment scheduling, billing functions for both patient and insurance, and the capability to verify insurance coverage online. A prescription writing feature may be included with some packages and a feature that includes various reports that may be needed for administrative purposes. An important feature to consider is a financial reporting option that will show ongoing balances on patients including the ins and outs of billing, payments, and charges. Some companies that offer this type of program will usually provide an animated demo of different modules and how to look up or input information.

Analyzing medical records through assigning codes, classifying diagnoses, and procedures, and keeping track of patient records is possible with most medical billing software. Laboratories, private practices, and specialty clinics can use these programs for billing purposes as well as patient registration, appointment scheduling, and other automated options, such as verification through insurance companies or discount services. Some programs allow the capability of showing test results, and adding comments to patient's files. Training is usually easy with online programs that charge based upon a monthly service fee and support is available through them whenever needed.

While web-based programs offer many important benefits, there are other options online for purchasing programs as well. Do a search for medical office management software and compare the price of purchase against a Web-based program while taking into consideration all the variables of using both types of packages. Programs that can be purchased online vary in costs and usually involve obtaining additional user licenses as well as purchasing upgrades from time to time, and don't forget to consider backup requirements, hardware requirements, and the features associated with desirable systems. Other considerations when purchasing packages are the ability to use it for outgoing house calls or home health care.

Systems available for medical billing software offer products that are easy to use for home health care and private duty care. Screen layouts provide easy use and many programs have built in tutorials that show how to navigate and enter information through various screens and modules. The organization of patient records is vital so that more time can be placed upon patient care and less time on record keeping. Cycles are automatically generated through many packages and can be customized based upon frequency of billing. When performing home health care, use a laptop or access any computer, to enter vital patient information while administering care. "And went to him, and bound up his wounds, pouring in oil and wine, and set him on his own beast, and brought him to an inn, and took care of him" (Luke 10:34). Keeping records simultaneously while providing care will prove more accurate and in the patient's best interest than trying to record vital information later. Home health care givers will appreciate being able to eliminate note taking since most packages include space to add comments on procedures and care given to patients.

Physician's on-call can use a palm pilot to record vital patient information while away from the office when using medical office management software. Information can be accessed for review and the physician can review all patient demographics, procedures, and financial records at any time. Palm pilot synchronization and customization is possible through a desktop computer so that the physician can become familiar with a structured way to access and input information. The capability of using any computer or a palm pilot makes these types of programs attractive to physician's who do home health care or may be out of town due to a seminar or company related function, especially when the need arises to access information from the office from time to time.





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