The first step in entering a registration form is to analyze the form and make sure you know who is the guarantor, who is the patient, and how many insurances they have. In many cases new trainees miss the information for the secondary insurance. Additionally, note who are the policyholders of the insurances. At times all three parties (guarantor, patient, policyholder) may be different people.
Health Insurance Portability and Accountability Act (HIPAA) defines fraud as an intentional deception or misrepresentation that someone makes, knowing it is false, that could result in an unauthorized payment. Abuse involves actions that are inconsistent with accepted, sound medical, business, or fiscal practices. Abuse directly or indirectly results in unnecessary costs to the program through improper payments. Wastemeans the over-utilization of services not caused by criminally negligent actions; waste involves the misuse of resources. Health care fraud, abuse and waste together cost the American Healthcare System more than $54 billion in one year. This is a big amount; something has to be done to prevent the health caresystem from fraud, waste, andabuse.
In the health care industry, it is necessary for the professionals to understand the process of accounts receivable becausethe health care organization is dependent on the cash inflow. Accounts receivable is the amount coming into the facility from various sources. The main sources of accounts receivable into a medical facility are the payments received from the insurer (insurance company) and the patient/policyholder. Accounts receivable are collected as a result of a cycle of activities. In the accounts receivable cycle, there are few steps for receiving payment from the insurer and the patient. Explanation of health care reimbursement system for each of them are as follows,
Prior authorization refers to the process whereby a provider tries in advance to get approval for a service that has been recommended for diagnostic or therapeutic purposes. Some carriers call it prior approval or pre-certification. Most managed care or government-sponsored carriers require that extensive or expensive procedures are reviewed before they are performed, if the provider wants to receive payment.
At the time of service, most provider facilities do not collect 100% of the amount that gets charged to their patients. Therefore, over time the accounts receivable will become past due and there must be some way of keeping track of and attempting to collect these amounts. The aging report, which is a systematic listing of how much patients owe to the doctor arranged by how long the amounts have been owed, is useful for these purposes.
These two medical billing programs are used mostly for billing for doctors professional services. The programs have many things in common, but several important differences.
The most noticeable difference is the user interface: while Medisoft users will feel perfectly comfortable in a standard MS Windows environment (MS Access was used to build Medisoft), Medical Manager users will have to get used to working in the non-GUI environment, which has been enhanced to utilize help windows and other convenient tools.