Sometimes the best way to ensure that all of the information is provided for effective Otolaryngology billing and coding is to educate staff about the ENT claims submission process. Learning about the importance of providing complete information for patients, including exams, diagnosis, and treatment, can ensure that billing and coding services are performed properly and without delay. Before your billing department even processes the information to submit medical billing claims, your medical team needs to provide the key data required to perform these tasks accurately. Your practice relies on the abilities and responsibility of each member of your team to ensure that claims are properly processed.
How Does It Work?
In short, the claims process involves communication between the healthcare provider, the policyholder, and the insurance company to ensure proper payment for services rendered. The practice or clinic is the healthcare provider, which is responsible for proper billing and coding services of all patient care that is provided during the visit. Much of the work that is done concerning the ENT claims submission process occurs at the office level. Making sure that your in-house billing department knows how to properly submit medical billing claims and that their knowledge and use of Otolaryngology billing and coding is up-to-date is essential to the ongoing success of your business.
The insurance companies receive the claims and process them on their end to ensure that covered services are properly paid for on behalf of the policyholder or patient. Whether the insurance is purchased privately or obtained through an employer, the process is essentially the same across the board. While there are different types of insurance policies and many levels of coverage available, all operate under the same business model in which the policyholder pays a certain amount of money each month in the form of a premium. Qualified procedures and services are paid for by the insurance company, either in full or in part. Any co-pay or deductible amount is the responsibility of the policyholder, and should be paid at the healthcare provider’s location before services are rendered.
What Happens Next?
After the patient or policyholder is seen by the healthcare provider or physician, the process between the healthcare provider and the insurance company begins. The healthcare provider records all of the medical services provided during the visit, including the initial exam, any testing that was performed, the diagnosis of the condition, and any subsequent treatment that is offered. The ENT claims submission process charges the healthcare provider with the responsibility of creating a comprehensive record of each visit to send the claims out to the policy holder’s insurance company for processing. The proper coding, according to ICD-10 regulations, must be used for each item before the healthcare provider can submit medical billing claims or it will be denied or rejected, depending on the issues with the claim.
Once the claim reaches the office of the insurance company, there are a few things that can happen. The first and best-case scenario is that the insurance company accepts all of the expenditures and pays the bill in full. This means that the healthcare provider performed all billing and coding services properly to ensure full payment for services rendered. The next option is for the insurance company to deny the claim due to a billing error, which means that the claim is then returned to the provider to be corrected. The third option is to outright reject the claim outright, which usually means that the services were not covered within the policy holder’s health plan. This means that the policyholder would then be responsible for paying for the claimed services out of pocket.
Two Types of Insurance Companies
Your front desk staff is charged with taking down all patient information, including copies of insurance cards and details about co-payments and deductibles that must be paid by the policyholder. While most Americans receive their insurance coverage either through an employer or by purchasing a managed care plan on their own, there are some who rely on public insurance coverage. Managed services can include HMO, PPO, and Point-of-Service plans, which are kind of like a hybrid between the HMO and PPO services. There are many differences in how claims are processed by HMO and PPO providers. All healthcare providers that are within a managed care network must file a claim with the HMO. However, when it comes to PPOs, the policyholder may need to file the claim on their own, especially if they seek treatment outside of the managed care network.
The two most well-known types of public insurance coverage include Medicaid and Medicare. Medicaid is a health service program designed for low-income families and individuals. While this coverage is federally mandated, the health coverage received is decided by the state in which the policyholder resides. The states make the payments on a fee-for-service system through arrangements with various HMO insurance programs. Medicare is also funded by the government, but is designed for the elderly. The basic coverage program is known as Part A, however recipients can also be eligible for additional coverage under Part B, which is also known as Supplementary Medicare. The ENT claims submission process for Medicaid and Medicare are similar to managed care services, but have some unique requirements of their own.
Educational Services for ENT Billing and Coding Services
If you are interested in learning more about our educational, training, and support services for Otolaryngology billing and coding, contact MD Pro Solutions at 508-946-1665. We can answer any questions that you might have about programs designed to improve your in-house billing department’s abilities to submit medical billing claims or schedule an appointment for a FREE initial consultation. Call today for custom solutions designed to enhance your practice’s ENT claims submission process.