Intechno China Inc.

The “P” of HIPAA
The P in HIPAA stands for portability of medical coverage. This part of HIPAA went into effect on July 1, 1997. On the date the plan or insurer becomes subject to the HIPAA provisions, the plan or insurer may not exclude coverage for any pre-existing medical conditions for more than 12 months after an individual’s enrollment date (18 months for a late enrollee).
In addition, the medical plan must count any creditable coverage that individuals accumulated prior to their enrollment date to reduce their remaining pre-existing condition exclusion period. So what does this mean? Suppose a new employee has had continuous creditable coverage for 9 months prior to the effective date of the new employer coverage. The new medical plan can enforce a waiver of any pre-existing conditions for a maximum of three more months. After 12 months of continuous creditable coverage, all pre-existing conditions must be covered as any other illness. It also means that if the employee has had at least 12 months of coverage prior to the new coverage, then no pre-existing conditions can be waived.
A late enrollee is an employee that does not elect coverage when offered and delays joining the medical plan. The creditable coverage period can be extended to 18 months. However, if the employee still has 18 continuous months of coverage, pre-existing conditions are still covered.
The concept of portability means an individual receives credit for maintaining health coverage, even though it may be under different health plans or policies. Portability does not mean that individuals can carry current health benefits or their current plan or policy with them when moving from one health plan or policy to another (such as when changing or losing jobs). Whatever the new plan covers is the coverage received. It means that the new plan can not exclude pre-existing conditions.
HIPAA also guarantees access to health coverage for small employers. Small firms (50 or fewer employees) are guaranteed access to health insurance, and generally, no insurer can exclude a worker or family member from employer-sponsored coverage based on health status. Insurers are required to renew coverage to all groups, regardless of the health status of any member. This is effective July 1, 1997.

Pre-existing Conditions
A “preexisting condition exclusion” is a limitation or exclusion of health benefits based on the fact that a physical or mental condition was present before the first day of coverage. However, HIPAA limits the extent to which a plan or issuer can apply a pre-existing condition exclusion.
A pre-existing condition exclusion is limited to a physical or mental condition for which medical advice, diagnosis, care, or treatment was recommended or received within the 6 month period ending on the enrollment date in a plan or policy.
During the pre-existing condition exclusion period, the plan or issuer may opt not to cover or pay for treatment of a medical condition based on the fact that the condition was present prior to an individual’s enrollment date under the new plan or policy. (The plan or insurer must, however, pay for any unrelated covered services or conditions that arise once coverage has begun.) The enrollment date is the first day of coverage, or if there is a waiting period before coverage takes effect, the first day of the waiting period.
Creditable Coverage
The concept of creditable coverage is that an individual should be given credit for previous health coverage against the application of a pre-existing condition exclusion period when moving from one group health plan to another, from a group health plan to an individual policy, or from an individual policy to a group health plan.
An individual will receive credit for previous coverage that occurred without a break of 63 days or more. However, any coverage occurring prior to a break in coverage of 63 days or more would not have to be credited against a pre-existing condition exclusion period. (Some States’ laws may provide greater protections.) If 63 days pass without coverage, then the 12/18 month period starts over.
Most health coverage is creditable coverage, including prior coverage under:
• a group health plan (including a governmental or church plan)
• health insurance coverage (either group or individual)
• Medicare
• Medicaid
•  military-sponsored health care program such as CHAMPUS
• a program of the Indian Health Service
• a State high risk pool
• the Federal Employees Health Benefit Program
• a public health plan established or maintained by a State or local government and
• a health benefit plan provided for Peace Corps members.
Creditable Coverage Certificate
A certificate of creditable coverage is a written document specifying the period of an employee’s creditable coverage. In certain circumstances, the certification information may be provided by telephone if that is acceptable to the new plan or issuer, the individual, and the source of prior coverage.
All employees must be given a “certificate of creditable coverage” by you, if you are self insured, or through the insurer offering health coverage. A certificate of creditable coverage must be provided without charge and within a reasonable time period.
The certificate must be furnished automatically to:
• an individual whose group coverage has ended, such as when they leave or quit a job. The certificate then must be provided within a reasonable length of time.
• an individual who loses health coverage and who is not entitled to elect COBRA continuation coverage. Then, the certificate must be provided within a reasonable time after coverage ceases. (Typically, this would happen in small-employer plans that are not subject to COBRA.) The certificate must be provided no later than when a notice would be provided under an applicable State program that is similar to COBRA. A certificate also must be provided promptly in States that do not have such a law.
• an individual who is qualified for COBRA and has elected COBRA continuation coverage or after the expiration of any grace period for the payment of COBRA premiums.
Certificates on request:
• Employees and their dependents also can ask for a certificate, which can be done any time within the 24 months following loss of coverage. The plan or issuer must provide certificates at the earliest feasible time after they are requested.
In general, employees should receive a certificate from their prior plan or issuer when they cease coverage. This certificate contains information that will demonstrate creditable coverage.
If employees do not have a certificate available, they can use a variety of evidence to prove creditable coverage. Acceptable documentation includes: pay stubs that reflect a coinsurance deduction, explanation of benefit forms (EOBs), verification by a doctor or former health care benefits provider that the employee had prior health coverage, and a benefit termination notice from Medicare or Medicaid.
Sample Certificate of Coverage click here
HIPAA is not the same as COBRA
HIPAA responsibilities do not eliminate or replace small employers’ responsibilities under COBRA, but there are some places where they are coordinated.
HIPAA makes three changes to COBRA’s continuation coverage. These changes were effective on January 1, 1997, regardless of when the event occurs that entitles the individual to continuation coverage.
• A disabled individual (as determined under the Social Security Act) is entitled to 29 months of COBRA continuation coverage. Under prior law, the individual had to be disabled at the time of termination of employment or reduction in hours. Under HIPAA, an individual is entitled to 29 months of COBRA coverage if he/she becomes disabled at any time during the first 60 days of COBRA coverage. The extension of continuation coverage to 29 months also is available to any non-disabled family members of the disabled individual who are entitled to COBRA continuation coverage.
• COBRA continuation coverage generally can be terminated when an individual becomes covered under another group health plan. COBRA cannot be terminated because of other coverage where the plan limits or excludes coverage for any pre-existing condition of the individual. HIPAA limits the circumstances under which a plan may impose a pre-existing condition exclusion period on individuals. If a plan is precluded under HIPAA from imposing an exclusion period on an individual, i.e., it must cover the individual’s pre-existing condition, COBRA continuation coverage may be terminated.
• COBRA rules also are modified to provide that children who are born, adopted, or placed for adoption with the covered employee during the continuation coverage period are treated as “qualified beneficiaries.” (Under prior law, to be a “qualified beneficiary” the child would have to have been covered under a group health plan on the day before the COBRA qualifying event.)

---

[Translate]

HIPAA is an acronym for the Health Insurance Portability and Accountability Act. This Act was introduced in 1996, but not fully implemented until 2003. HIPAA was created to insure that people between jobs would still have access to quality health care coverage, since in the past it was difficult or impossible to change insurance carriers without facing lowered coverage or exorbitant premiums. HIPAA was also intended to protect private health care information and create a uniform standard for dispersing personal information. continue reading…

---

[Translate]

The modifier was created for situations when the physician needs to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the other procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier ‘25′ to the appropriate level of E/M service. Modifier 25 is used to identify a significant, separately identifiable evaluation and management service performed on the same day as another procedure or service by the same provider. continue reading…

---

[Translate]

I am writing this article again as a suggestion from many of my readers on my blog.

This article is more comprehensive in a way that scenarios were cited to have a

bigger look on the proper use of some of these important modifiers.
In this article, I will be describing the medical claims modifiers - Modifier -25, -

24, -51, -57, -59, -26.
Modifier -25, 25: Significant, separately identifiable evaluation and management

service by the same physician on the same day of the procedure or other service:
This modifier must be appended with an E/M service. This is the modifier you will

need to use with the evaluation and management service done on the same day with

other procedure done by the same physician. It has to be above and beyond the usual

preoperative and postoperative encounter with the procedure. In fact, by using this

modifier, it doesn’t have to have a different diagnosis reported. The most important

thing is that, the E/M level should meet its key components or if it is selected

based on time with the patient (counseling and coordination). You have to be careful

in using this modifier. It must meet medical necessity. As you know, there are

procedures that already includes all other care and management. continue reading…

---

[Translate]

Medical billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned.

Billing Process
The billing process is an interaction between the provider and the insurance company (payer). It begins with the office visit. After the provider sees the patient, depending on the service provided and the examination, the doctor creates or updates the patient’s medical record. This record contains a summary of treatment and demographic information [Commonly-used demographics （demographic information or data） include sex, race, age, income, disabilities, mobility (in terms of travel time to work or number of vehicles available), educational attainment, home ownership, employment status, and even location.]related to the patient. Upon the first visit, the provider will usually give the patient a diagnosis (or possibly several diagnoses), in order to better coordinate and streamline his/her care.
The treatment, diagnosis, and duration of service combine to determine the procedure code that will be used to bill the insurance. The doctor then either provides this information to a medical coder or other billing specialist. From this, a billing record, either paper (usually on a standardized form called an HCFA) or electronic, is generated. This form includes the various diagnoses identified by numbers from the current ICD-9 manual.
This billing record or claim is then submitted either to a clearinghouse that acts as an intermediary for the information (this is typical for electronic billing) or directly to the insurance company.
The insurance company (payer) processes the claim. The insurance side of the process begins with testing the validity of the claim for payment. The tests cover patient eligibility for payment, provider credentials, and medical necessity. Upon passing successfully the tests, the payer pays the claim. If a claim fails the tests, the payer rejects the claim and communicates the rejection message to the claim submission source.
Upon receiving the rejection message, the provider must decipher the message, reconcile it with the original claim, make required corrections, and resubmit the claim again. This exchange of claims and messages may repeat multiple times until the claim is paid in full.
The frequency of rejections, denials, and underpayments is high (often reaching 50%), mainly because of high complexity of claims and data entry errors. Straight Through Billing technology, procedures, and training help manage the billing process to receive all payments on time.

Billing Quality
Billing Quality is measured in terms of timeliness and completeness of payment. The shape of the distribution curve of Accounts Receivable illustrates billing quality. Specific measures include median and percent of accounts receivable beyond 30 days, 60 days, and 120 days. A good quality billing process has relatively small median, e.g., half of the claims must be paid within 30 days, and a steep drop in terms of percents of accounts receivable, e.g., reaching less than 10% of A/R beyond 120 days. The actual amount of Accounts Receivable beyond 120 days is considered uncollectable and labeled as a provider’s loss for write off.

Billing Transparency
Billing Transparency allows every participant in the billing process to see continuously both its big picture and the minute detail. The big picture consists of total cash flow in a given time period, current submitted and failed claims, and Billing Quality. The minute detail pertains to individual claims making up the big picture, including complete history from the moment of creating the claim, testing its validity, corrections, submissions, and reconciliations, until payment.
Straight Through Billing
Straight Through Billing integrates billing process within the practice management workflow, connecting patient scheduling, care delivery, and medical record management. Every participant of the practice management workflow receives a unified and coherent picture of practice workload, patient and provider location, resource availability, and cashflow. Straight Through Billing requires integrated technologies for Electronic Medical Records (EMR) and Straight Through Billing.
Straight Through Billing Technology
Straight Through Billing technology streamlines and expedites billing process by automating claim validation, payer message reconciliation, and billing workflow management. First, automated claim validation eliminates errors downstream and reduces processing time because it flags errors before submitting the claim to payer. Next, automated claim-message reconciliation eliminates costly search for the original claim and standardizes message communication, further eliminating the need to decipher the (often cryptic) payer’s message. Finally, billing workflow management drives the followup discipline required for resolution of claim denial and underpayment incidents and establishes high degree of process transparency for all billing process participants, resulting in full and timely payments.

History
For several decades, medical billing was done almost entirely on paper. However, with the advent of computers it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market.
The billing field has been challenged in recent years due to the introduction of the HIPAA act. Due to the many restrictions that were enacted as a result of this new law, many software companies and medical offices spent thousands of dollars on new technology and were forced to redesign and rebuild their business processes and software in order to become compliant with this new act.

Terms and Codes
Knowing common abbreviations and terms is the key to deciphering a medical bill. A partial list follows:
• ANES: Anesthesia service administered by anesthesiologist.
• DESFLURANE: A breathable anesthesic.
• GROUNDING PAD or PATIENT PLATE or RETURN ELECTRODE: A Dispersive Electrode which can safely direct electrical charges out of the patient’s body to prevent burn.
• STERI STRIPS: Sterilized strips of bandaging.
• PACU: Post Anaesthesia Care Unit. The area one is placed after surgery is complete.

---

[Translate]

Medical billing is the process of submitting and following up on claims to insurance companies in order to receive payment for services rendered by a healthcare provider. The same process is used for most insurance companies, whether they are private companies or government-owned.

Billing Process
The medical billing process is an interaction between a healthcare provider and the insurance company (payer). The interaction begins with the office visit: A doctor or their staff will typically create or update the patient’s medical record. This record contains a summary of treatment and demographic information related to the patient. Upon the first visit, the provider will usually give the patient one or more diagnoses in order to better coordinate and streamline his/her care. In the absence of a definitive diagnosis, the reason for the visit will be cited for the purpose of claims filing. The patient record contains highly personal information: the nature of illness, examination details, medication lists, diagnoses, and suggested treatment.
The extent of the physical examination, the complexity of the medical decision making and the background information (history) obtained from the patient are evaluated to determine the correct level of service that will be used to bill the insurance. The level of service, once determined by qualified staff is translated into a five digit procedure code from the Current Procedural Terminology. The verbal diagnosis is translated into a numerical code as well, drawn from the ICD-9-CM. These two codes, a CPT and an ICD-9-CM, are equally important for claims processing.
Once the procedure and diagnosis codes are determined, the medical biller will transmit the claim to the insurance company (payer). This is usually done electronically by formatting the claim as an ANSI 837 file and using Electronic Data Interchange to submit the claim file to the payer directly or via a clearinghouse. Historically, claims were submitted using a paper form; in the case of professional (non-hospital) services and for most payers the CMS-1500 form or HICF (Health Insurance Claim Form)was and is still commonly used. The CMS-1500 form is so named for its originator, the Centers for Medicare and Medicaid Services. To this day about 30% of medical claims get sent to payers using paper forms which are either manually entered or entered using automated recognition or OCR software.
The insurance company (payer) processes the claims. The insurance company has medical directors review the claims and evaluate their validity for payment using rubrics for patient eligibility, provider credentials, and medical necessity. Approved claims are reimbursed for a certain percentage of the billed services. These rates are pre-negotiated between the health care provider and the insurance company. Failed claims are rejected and notice is sent to provider. Most commonly, rejected claims are returned to providers in the form of Explanation of Benefits (EOB’s) or Remittance Advice.
Upon receiving the rejection message the provider must decipher the message, reconcile it with the original claim, make required corrections and resubmit the claim. This exchange of claims and rejections may be repeated multiple times until a claim is paid in full, or the provider relents and accepts an incomplete reimbursement.
The frequency of rejections, denials, and over payments is high (often reaching 50%)(HBMA 7/07), mainly because of high complexity of claims and/or errors due to similarities in diagnosis’ and their corresponding codes. This number may also be high due to insurance companies denying certain services that they do not cover (or think they can get away without covering) in which case small adjustments are made and the claim is re-sent.

Electronic Billing Process
A practice that has interactions with the patient must now under HIPAA send most billing claims for services via electronic means. Prior to actually performing service and billing a patient, the care provider may use software to check the eligibility of the patient for the intended services with the patient’s insurance company. This process uses the same standards and technologies as an electronic claims transmission with small changes to the transmission format, this format is known specifically as X12-270 Health Care Eligibility & Benefit Inquiry transaction. A response to an eligibility request is returned by the payer through a direct electronic connection or more commonly their website. It is called an X12-271 “Health Care Eligibility & Benefit Response” transaction. Most practice management/EMR software will automate this transmission, making them hidden from the user.
This first transaction for a claim for services is known technically as X12-837 or ANSI-837, and it contains a large amount of data regarding the provider interaction as well as reference information about the practice and the patient. Following that submission, the payer will respond with an X12-997, simply acknowledging that the claim’s submission was received and that it was accepted for further processing. When the claim(s) are actually adjudicated by the payer, the payer will ultimately respond with a X12-835 transaction, which shows the line-items of the claim that will be paid or denied; if paid, the amount; and if denied, the reason.
Due to limited technology, many payers (especially states’ Medicaid) still adjudicate claims manually; this results in significant delays — up to 48 hours or even weeks to issue 835 responses to properly submitted 837 transactions. In many cases this manual processing subverts the entire point of Congress in mandating a standardized electronic billing process. These delays can also present catastrophic problems to the availability of healthcare for those patients with difficult payers — such as happened in California with the state Medicaid program referred to as “Medi-cal”.

Payment
In order to be clear on the payment of a medical billing claim, the health care provider or medical biller must have complete knowledge of different insurance plans that insurance companies are offering, and the laws and regulations that preside over them. Large insurance companies can have up to 15 different plans contracted with one provider. When providers agree to accept an insurance company’s plan, the contractual agreement includes many details including fee schedules which dictate what the insurance company will pay the provider for covered procedures and other rules such as timely filing guidelines.
Providers typically charge more for services than what has been negotiated by the doctor and the insurance company, so the expected payment from the insurance company for services is reduced. The amount that is paid by the insurance is known as an allowable amount. For example, although a psychiatrist may charge $80.00 for a medication management session, the insurance may only allow $50.00, so a $30 reduction would be assessed. This is called a “provider write off” or “contractual adjustment.” After payment has been made a provider will typically receive an Explanation of Benefits (EOB) or Electronic Remittance Advice (ERA) along with the payment from the insurance company that outlines these transactions.
The insurance payment is further reduced if the patient has a copay, deductible, or a coinsurance. If the patient in the previous example had a $5.00 copay, the doctor would be paid $45 by the insurance. The doctor is then responsible for collecting the out-of-pocket expense from the patient. If the patient had a $500.00 deductible, the contracted amount of $50 would not be paid by the insurance company. Instead, this amount would be the patient’s responsibility to pay, and subsequent charges would also be the patient’s responsibility, until his expenses totaled $500. At that point, the deductible is met, and the insurance would issue payment for future services.
A coinsurance is a percentage of the allowed amount that the patient must pay. It is most often applied to surgical and/or diagnostic procedures. Using the above example, a coinsurance of 20% would have the patient owing $10 and the insurance company owing $40.
In Medicare the physician can either be ‘Participating’ in which he will receive 80% of the allowable Medicare fee and 20% will be sent to the patient or can be ‘Nonparticipating’ in which the physician will receive 80% of the fee, and may bill patients for 15% or more on the scheduled amount.
For example the regular fee for a particular service is $100, while Medicare’s fee structure is $70. Therefore the physician will get $56, and the patient will pay $14. Similarly Medicaid has its own set of policies which are slightly more complex than Medicare.
Steps have been taken in recent years to make the billing process clearer for patients. The Healthcare Financial Management Association (HFMA) unveiled a “Patient-Friendly Billing” project to help healthcare providers create more informative and simpler bills for patients. Additionally, as the Consumer-Driven Health movement gains momentum, payers and providers are exploring new ways to integrate patients into billing process in a clearer, more straightforward manner.

History
For several decades, medical billing was done almost entirely on paper. However, with the advent of medical practice management software also known as health information systems it has become possible to efficiently manage large amounts of claims. Many software companies have arisen to provide medical billing software to this particularly lucrative segment of the market. Several companies also offer full portal solutions through their own web-interfaces, which negates the cost of individually licensed software packages.
Due to the rapidly changing requirements by U.S. health insurance companies, several aspects of medical billing and medical office management have created the necessity for specialized training. Medical office personnel may obtain certification through various institutions who may provide a variety of specialized education and in some cases award a certification credential to reflect professional status. The Certified Medical Reimbursement Specialist (CMRS) accreditation by the American Medical Billing Association is one of the most recognized of specialized certification for medical billing professionals.

HIPAA
The billing field has been challenged in recent years due to the introduction of the Health Insurance Portability and Accountability Act (HIPAA).
HIPAA is a set of rules and regulations which hospitals, doctors, healthcare providers and health plans must follow in order to provide their services aptly and ensure that there is no breach of confidence while maintaining patient records.
Since 2005, medical providers have been urged to electronically send their claims in compliance with HIPAA to receive their payment.
Title I of this Act protects health insurance of workers and their families when they change or lose a job. Title II calls for the electronic transmission of major financial and administrative dealings, including billing, electronic claims processing, as well as reimbursement advice.
Medical billing service providers and insurance companies were not the only ones affected by HIPAA regulations - many patients found that their insurance companies and health care providers required additional waivers and paperwork related to HIPAA.
As a result of these changes, software companies and medical offices spent thousands of dollars on new technology and were forced to redesign business processes and software in order to become compliant with this new act. If an insured claim is billed by another insured with a different name than that might be a big issue by the insurance companies.

Demographics
The medical billing specialists enter patient, and if applicable guarantor demographic details such as name, date of birth, address, insurance details as provided by the patients at the time of the visit. For established patients, these details are validated.

---

[Translate]

Patient Demographics and Charge Entry Solutions
Intechno offers a full range of outsourced medical billing solutions and services for patient account creation, charge entry, and patient demographics entry. Our patient demographics and charge entry medical billing solutions can work from scanned images as well as electronic data.

Our services include:
• Eligibility verification
• Pre-authorization
• Patient Demographics and charge entry continue reading…

---

[Translate]