Saturday, August 15, 2009

Primer #1: American Health Billing Basics

Can it be MORE Complicated?

The Headache is behaving itself this evening. Could it be the stimulator? Hard to tell, as I am taking a bunch of antihistimines to quell The Hives. The Belly is feeling that it is over The Flu. Yeah!

As a review for myself (I will soon be working with a new hospital client) I thought I would share some information about medical billing. You will probably find this boring, but I deal with this every day. I will write about this subject again next week if The Headache behaves and The Brain is still working, so you have advance warning and can skip reading that day!

HIPAA: Health Insurance Portability and Accountability Act. This is why you have to sign the same "Privacy Forms' over and over again saying if you can be contacted by phone, a message left, who can share your priveleged health information. If you suspect that your healthcare information has been improperly accessed/shared you have to report the breach of confidentiality yourself. This law is enforced on a complaint basis only, so there are no "security HIPAA audits" being given by the federal government to insure compliance. The law protects employees so they can move from job to job and their preexisting health conditions cannot not be excluded from their next employer based health insurance policy. It is also supposed to "simplify" medical billing processes, but like many federal laws just made them more complex. There are many loopholes in this statute, even in the part about protecting your right to coverage.

Subscriber ID: This is a unique identifier your health insurance entity has assigned to you. This identifier allows your health insurance company to process your health insurance claims with the proper pricing structure for your health plan. A group name and number may also apply. If you are an old fashioned Medicare recipient, your subscriber ID is called a HICN (Hic Number) Health Insurance Claim Number. This ID can also be called a certificate number, as health insurance policies issue a certificate of insurance stating the boundaries of your policy. Information may be encoded within your ID about your policy, your marital status, whether or not you are a dependent of the policy holder or the policy holder yourself, your employer, and with Medicare whether you are a retired railroad worker or not.

Pre Determination: Your insurance company can pre-determine if they will pay for certain services before you have them done. An example would be my occipital stimulator surgery. Since it is considered "investigational" by my insurance company, if I had not been in the study I would have asked for an official Pre-Determination. If the Pre-Determination process said the surgery would not be covered, I would then have to appeal the Pre-Determination. Dental services often get pre determinations for full plans of treatment.

Prior Authorization/Pre Certification: These terms are synonymous. They are approval from your insurance company stating that a service is already authorized before it is done/issued/billed. If the service needs prior authorization/pre certification and for some reason it was not OK'd, healthcare entities will ask you to sign that you will be financially responsible for it if the claim does not go through. Unless you are certain that you want this service done and pay for it, try to see if there is a problem with the prior authorization/pre certification paperwork. Sometimes a peer to peer review can be done about the authorization request (this means your doctor talking to an insurance company doctor) and sometimes you can appeal the denial. There is a specific number given for each authorization and a date range that the authorization is effective. Your claims when processed will be compared to these authorizations to see if one applies. Some drug plans refuse to cover high dollar name brand drugs or certain allergy drugs unless the drug has prior authorization/pre certification from the ordering physician.

Advance Beneficiary Notice: For Medicare recipients healthcare entities are supposed to notifiy the patient/responsible party that an outpatient service is NOT covered by Medicare and present this information in writing to the recipient, giving the patient the opportunity to refuse the service, or agree to pay if it is not paid by Medicare. If the healthcare entity does not do this, and the service is not paid by Medicare, the patient cannot be billed for this service.

Appeal: This process may vary insurance company to insurance company and state to state. In my state you are entitled to three levels of appeal. Many claims are considered at the first level of appeal. In general each level of appeal is handled by persons higher and higher in the chain of command of the insurance company who have more authority to make determinations about "grey" areas of coverage. A lot of the process for payment of claims is done by computers and sometimes yes or no decisions that computers like to make do not take in all aspects of a situation. There are ways to bypass the computer system by "adjusting" a claim to pay a certain way but this is only done once an appeal or readjudication (repayment) is requested and granted.

Adjudication: Final payment determination of a health insurance claim.

Primary/Secondary/Tertiary: The order in which insurances are billed. If there are two insurance coverages for the same person (for example both the patient and the patient's spouse have insurance on the patient) some insurance companies use something called "The Birthday Rule" to decide which coverage gets to be the primary coverage: the insurance paid for by the person whose birthday is the earliest in a calendar year is considered primary. Primary insurance is billed first, secondary insurances only consider what the primary did not pay, and tertiary insurance often doesn't have anything left to pay. If Medicaid is one several payors, it is always the "payor of last resort" and not the primary. Medicaid is primary only if it is the only payor.

Coordination of Benefits (COB): A department in your insurance company that looks at claims that have more than one possible source of payment. They often write letters asking for more information. The purpose of this department is to see if the anyone else could possibly pay for your claim. Certain diagnosis that are considered trauma related (broken bones, cuts, back surgery) will often be automatically routed to this department since there may be other companies/persons liable for the injury.

Medicare Secondary Questionnaire: A recommended series of questions for Medicare recipients to determine if another source could be billed for services other than Medicare. An example would be someone who has a Black Lung card and is being seen for complications from Black Lung. This person is also disabled and has Medicare coverage. In this case, the Black Lung program would be billed as that is the problem being treated, and Medicare would be "secondary" to Black Lung, so would only pay the remainder the Black Lung program wouldn't pay. There are different questions about spousal insurance, and coordination periods based on why the person is eligiable for Medicare: 1 - age related eligibility (older persons) 2- disability related eligibility 3-ESRD related eligibility (end stage renal disease). This is tricky to navigate through and Medicare patients get confused by all the questions. Similar to the COB deparment at private insurances, trauma codes may be reviewed by the Medicare claim processing intermediary for other primary payors. Medicare is looking for someone else who could pay this bill just like the private insurance companies do.

This is just the tip of the billing iceberg. No wonder patients with billing/coverage issues feel they are sinking in icy waters just like the Titanic! Its the mountain under the water not the little bit sticking up on top you can see that's the problem. I'm hoping that the healthcare reform being contemplated gives us all enough life boats to get to safety!

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