Medical claim processing is a sore spot with almost all physicians today and to submit on paper without software today is a nightmare.  At EZClaim we have several choices, depending on the size and number of claims your practice submits.  Take a look at our website and see which one is a good fit for your needs.

The report from the AMA states eligibility is one of the big areas for denial and this goes beyond just whether or not a patient is insured or not, as policies are more complex today, it may be a portion of the claim that is not eligible.   By using a clearinghouse service, you can be assured that your claims are correct in format; however denials go beyond just getting the numbers correct and we also offer our services to help.  With the complexity we all deal with today, billing on paper is almost a thing of the past.

This is what was published in Reuters this week:

CHICAGO, June 14 (Reuters) - Claims-processing errors by health insurance companies create billions of dollars in unnecessary administrative costs, slow down payments to doctors and frustrate patients, the main U.S. doctor’s group said on Monday.

The American Medical Association said one-fifth of all claims are mishandled by health insurers.

 Currently, the health care system spends as much as $210 billion annually on claims processing, according to the report issued at the AMA’s annual meeting. Doctors have long complained about excessive paperwork required to satisfy insurance companies.  The AMA described mishandling as claims processed with errors - underpaid, overpaid or incorrectly unpaid.

http://www.reuters.com/article/idUSN1422071220100614

It is sad to say but fraud seems to be everywhere today.  This was a scheme on the internet where people were lured into a “billing at home”business so a word to the wise no matter which side you are on, the billing or the provider side, make sure you are dealing with reputable people and companies.  EDI Healthclaims was the name of the business that settled with the FTC and the Department of Justice.

The reimbursement is for the money paid up front by an individual to get started with their business.

This week, an administrator working on behalf of the Federal Trade Commission mailed checks to 3,500 consumers nationwide who were defrauded by a group of marketers accused of hawking phony business opportunities. Consumers who were victims of this scam will receive a total of $95,000 in redress

The reimbursement stems from the February 2008 settlement of a case brought as part of a Commission-led law enforcement sweep that included more than 100 actions filed by the FTC, the Department of Justice, the U.S. Postal Inspection Service, and other agencies in 11 states. In this case, known as EDI Healthclaims, the FTC alleged that scammers used mass mailings to consumers offering a “work-at-home” business opportunity to earn easy money electronically processing health-care providers’ medical claims for insurance reimbursement.

 http://www.consumeraffairs.com/news04/2010/05/ftc_medical_billing.html

In the news lately with healthcare reform is also a crack down on billing fraud.   It happen everywhere with both Medicare and Commercial insurers.  Sometimes it is not caught until the patient ends up finding it on their tab.  Listed below are a couple examples of some pretty high bills found by patients themselves that are not related in any way to any condition they might have.

Efforts are being stepped up to use technology to audit and evaluate claims for potential fraud.  Sometimes the crooks do such a good job with accuracy, they get paid faster and sooner than providers.   In the next few years you can expect even more inquisitions as the government steps up their efforts to defeat fraud.  One of the biggest areas has been equipment fraud with wheelchairs and other items that are billed for patients who do not need them and in most of these cases the individuals committing fraud are just looking for a provider and patient name to bill.

March 23 (Bloomberg) — Sierra Morgan was billed $12,000 on her health-care credit card in November for liposuction, a procedure she never requested or had.

“It’s depressing to know that someone used my name and knows so much about me,” said the 31-year-old respiratory therapist from Modesto, California.

There were more than 275,000 cases in the U.S. last year of medical information theft, twice the number in 2008, according to Javelin Strategy & Research, a Pleasanton, California-based market research firm. The average fraud cost $12,100, Javelin said.

 Brandon Sharp, 38, found more than $100,000 of unpaid medical bills on his credit report when he went to buy a home. The charges included $19,501 for a life-flight helicopter trip and emergency room visits he never used, said Sharp, a project manager for an oil company in Houston, Texas. “I’m as healthy as they come,” he said.

 http://www.businessweek.com/news/2010-03-23/patient-billed-for-liposuction-as-medical-theft-rises-update1-.html

Do you get confused with how to code diabetes?  Are you coding for Diabetes 1 or type 2?  Below are a few hints that might offer some advice on how to get the coding done right.

When you read through the codes and use of insulin it can be a little confusing.  One of the big items to watch for is the difference between adults and juvenile use.  You can also visit the entire article source for additional information if needed.

Type 1 diabetes: results from the body’s failure to produce insulin, and presently requires the person to inject insulin.

Type 2 diabetes: results from insulin resistance, a condition in which cells fail to use insulin properly, sometimes combined with an absolute insulin deficiency.

Gestational diabetes: is when pregnant women, who have never had diabetes before, have a high blood glucose level during pregnancy. It may precede development of type 2 DM.

Diabetes Mellitus:- Codes under category 250 diabetes mellitus, identify complications/manifestation assocatied with diabetes mellitus. A fifth -digit is required for all category 250 codes to identity the type of diabetes mellitus and whether the diabetes is controlled or uncontrolled.

Fifth digits for category 250: The following are the fifth digits for the codes under category 250 are

0 – type II or unspecified type, not stated as uncontrolled

1 – type I juvenile type, not stated as uncontrolled.

2 – type II or unspecified type, uncontrolled.

3 – type I juvenile type, uncontrolled.

NOTES: Type I diabetes mellitus is also referred to as juvenile diabetes. If the type of diabetes mellitus is not documented in the medical record the default is type II.

Diabetes mellitus and the use of insulin:- All type I diabetes must use insulin to replace what their bodies do not produce. However, the use of insulin does not mean that a patient is a type I diabetic. Some patients with type II diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do required insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the appropriate fifth digit for type II must be used. For type II patient

Diabetes mellitus and the use of insulin:- All type I diabetes must use insulin to replace what their bodies do not produce. However, the use of insulin does not mean that a patient is a type I diabetic. Some patients with type II diabetes mellitus are unable to control their blood sugar through diet and oral medication alone and do required insulin. If the documentation in a medical record does not indicate the type of diabetes but does indicate that the patient uses insulin, the appropriate fifth digit for type II must be used. For type II patient

Use of insulin: Insulin should also be assigned to indicate that the patient uses insulin. Code V58.67 should not be assigned if insulin is given temporarily to bring a type II patient’s blood sugar under control during an encounter.

 http://www.articlebuster.com/2010/03/diabetes-medical-coding/