Glossary of Insurance and Medical Billing Terms

Following are some of the most common terms you may hear that are associated with your insurance plans and medical billing.

Ambulatory Surgery	Surgery done in the doctor’s office or at a surgical center, and not requiring an overnight stay.
Ancillary Providers	Services over and above physician services, including laboratory, radiology, home health and skilled nursing facilities.
Authorization	Approval of care required before a service is provided. Pre-authorization may be necessary before hospital admission, or before care is given by non-HMO providers.
Balance Billing	Billing a patient for charges not paid by their insurance plan because the charges are above the Usual and Customary Rate or because the insurer considered a procedure medically unnecessary.
Carve-out Policy	A contracted agreement between an insurance company and another company which provides special services to its members, such as prescription drugs or cancer treatment.
Case manager	A case manager is a trained insurance professional, primarily in the areas of long-term medical care, life insurance and annuities, which presides over a patient or client’s account. Case managers are prevalent in the healthcare industry.
Claim	A record of medical services provided to a patient and submitted by the provider to the insurance company for payment.
Claims Review	The method by which a patient’s health care service claims are reviewed before reimbursement is made. This is done to validate the appropriateness of services given and that the cost is not excessive.
Coinsurance	A provision which limits the amount of the coverage paid by an insurance plan to a certain percentage, with the remaining costs paid by the member.
Co-pay	Co-pay is the amount that a patient is responsible for at the time they visit a physician or hospital, or have a prescription filled. The patient is responsible for this up-front fee, while the insurance provider covers the remaining cost of a medical service or prescription.
CPT-4	A 5-digit code that applies to medical services delivered.
COBRA (Consolidated Omnibus Budget Reconciliation Act)	The COBRA Act allows for employees and their dependents to continue to receive insurance coverage after the loss of a job or reduction in hours. COBRA insurance is more expensive than group insurance, but is still usually less expensive than individual coverage.
Deductible	An insurance deductible is the amount that a policyholder is responsible for on a claim. Whether it is on an auto, homeowner’s or renter’s policy, the deductible must be paid before the insurer will cover any of the other expenses.
EOB (Explanation of Benefits)	A statement describing medical benefits and account activity, including explanation of why certain claims may or may not have been paid.
Exclusion	Services or supplies not covered under a health plan.
Fee Schedule	A listing of the maximum fee which a health plan will pay for services based on CPT billing codes.
Family and Medical Leave Act (FMLA)	The FMLA provides up to 12 weeks of unpaid leave per year for employees with medical issues, for those who are caring for family members, or for births and adoptions. All public agencies, elementary and middle schools, and businesses with more than 50 employees are subject to the FMLA guidelines.
Health Insurance Portability and Accountability Act (HIPAA)	This act, which was passed in 1996, helps ensure that privacy is maintained in regards to patients’ medical records. It also created a set of standards to which all electronic medical records must adhere.
ICD-9	A 3 to 5-digit number code describing a diagnosis or medical procedure.
Inpatient	A patient who is admitted to a hospital and receives medical services from a physician during at least a 24-hour period.
Insurance cap	An insurance cap is the total lifetime dollar amount that a provider will pay on a particular policy. Many insurance companies have a lifetime cap of $1 million, which can be easily attained in cases of prolonged medical treatment and care.
In-Network Provider	Physicians and other service providers who are contracted with a managed care plan.
Out-of-Network Provider	Physicians who are not contracted with a managed care plan.
Outpatient	A patient who receives health care services, but is not admitted to a hospital during a 24-hour period.
Patient Navigator	Patient Navigator is an organization that assists families with medical treatment options and with the explanation of insurance coverage and acts as a liaison with medical personnel.
Primary Care Physician	A physician, usually a general, family practitioner or internist, who delivers general health care, and is most often the first doctor a patient sees. This physician treats the patient directly, refers them to a specialist (or secondary care physician) or admits them to the hospital.
Provider	A physician, hospital, laboratory, pharmacy or other organization that provides health care, goods or services.
Pre-Certification	Also known as pre-admission certification, is the process of obtaining authorization from the health care plan for routine inpatient and outpatient admissions. Failure to obtain pre-certification may result in penalty to the provider or the subscriber.
Premium Pre-certification	Premium pre-certification occurs when a person requesting insurance coverage fills out additional paperwork to determine whether they meet the requirements for policy coverage. This occurs primarily in mental health insurance cases.
Referral Authorization	Approval for a member to see a physician or access services outside of the participating medical group.
Referral Physician	A physician who sees a patient after another doctor has sent them for specialty care or services.
Referring Physician	A physician who sends a patient to another doctor for specialty care or services.
Subscriber	A person who enrolls in a health care plan and agrees to pay for premiums, co-payments and deductibles that are part of the plan.
Treating Physician	A physician who provides care to the patient while in the hospital, and usually works at the hospital or comes in as a specialist.

Cardiology Billing

Cardiology Billing
If you are not aware and prepared for the 2009 cardiology billing and coding changes you may be leaving a lot of money uncollected. The 2009 coding and billing changes are the most significant for cardiology that have been seen since the mid 1990s.
While the average physician will see slightly over a 1% increase in Medicare fees, Cardiologists will see a 2% reduction in fees. This is mainly the result of lower payments for office-based imaging. Cardiologist that have a higher than average use of imaging services will see decreases in their Medicare fees far in excess of 2%, while other cardiologists may be able to achieve an increase in Medicare fees.
Here are examples of some of the upcoming changes:
• All of the codes previously used to submit charges for implanted device follow-up have been deleted and replaced with new codes. Not only have the old codes been replaced, but they have been replaced with a more updated code set that provides codes for checks of devices with leads in 3 chambers, codes specific to a remote (internet) device check, codes for following ICM devices, codes for per procedural checks, etc.
• Global periods related to device follow-up now include global periods of 30 or 90 days. The new codes are now service specific (i.e., either an interrogation evaluation of a programming evaluation).
• Wearable cardiac telemetry devices (for instance Cardio net type service) now have specific codes. You no longer bill with an unlisted code. These new codes include the complication of global periods.
• Codes that bundle multiple echo services under a single code have been introduced. Examples include a single CPT for bundling an echo with both a Doppler and color flow and a stress echo CPT that bundles both the stress test and stress echo.
As the examples above demonstrate, the magnitudes of this year’s cardiology billing changes are more significant that has been seen in recent years. Without proper education, training, software upgrades and billing resources cardiology practices may see marked reductions in collections and increases in AR.
Importance of Cardiology Billing
Medical billing is a crucial health care service that supports physicians by submitting and collecting the payments from insurance companies and patients. One needs to be an expert to ensure that the bills are collected fully and in a timely fashion. It is quite common for over 20% of a practice's potential revenue to remain unclaimed because of improper coding and weak collection strategies. Outsourcing medical billing is growing in popularity as an approach for addressing this tremendous loss of practice income. The range of outsourcing options runs from extremely large organizations to individual freelancers who work from home to provide medical billing services.
Medical billing is a highly complex area and it requires experience-based knowledge and expertise to contend with insurance companies. When it comes to cardiovascular billing, the situation gets even more complex. Such complexity can be handled only by a company that is staffed with well trained cardiology billing professionals. The medical billing specialist must be familiar with the specific codes and rules that make up the world of cardiac billing. Cardiovascular coding and cardiac billing cannot be done by everyone, it is a highly specialized field and it is not possible to be successful in collecting the bills fully from the insurance companies without the proper skills and training.
As the cost of providing cardiology related healthcare services continues to rise, medical institutions and cardiology practices cannot afford to leave revenue uncollected by billing companies or freelancers that are not knowledgeable in cardio billing. It is also important to keep in mind some companies may promote themselves as large cardiac billing service providers but in reality they sub-contract the cardiovascular billing to freelancers who work from home. Hiring such companies will lead to lost revenue because of the lack of proper process, controls, and training.
One of the major drawbacks of hiring a company that does not specialize in cardiology billing is their lack of familiarity with the procedures and the terminologies used. Even if the medical billing company serves one or two cardiologists, they will lack the depth and breadth of expertise required for successful cardiology billing. Moreover if the hired company does not specialize in cardiovascular billing, then they will not have the expertise to effectively appeal denied claims or answer questions raised by the insurance companies. A company that does not encompass a wide range of cardiology billing experience will find it difficult to track underpayments since multiple procedure rules, nuclear camera rules and cardiology procedures have significantly more complicated contractual adjustment rules than a typical family doctor or internist's claims. In addition, the billing software and system design of a generalist billing company will often be insufficient for the more complicated requirements of reporting and insurance follow-up required in cardiology billing.
These billing complications extend to the patient collections arena as well. The patient collection process for specialists like cardiologists is more complicated because of the large patient balances often owed, the complexity of the procedures/EOBs that must be explained to patients that do not understand their bills and the typically older population cardiologists serve. A medical billing service with expertise in cardiology billing knows how to deal with these situations. Billing services without such experience will increase the risk of both lower patient collections and upset patients confused about their bill.
To avoid all these billing related pitfalls cardiologists need to utilize specialized cardiology billing services. It is not advisable for an internist to perform cardiac surgery, similarly someone without training in cardiovascular coding and cardiology billing is not qualified to offer reliable billing services for cardiovascular practices.
2009 Challenges in Cardiology Billing
If you are not aware and prepared for the 2009 cardiology billing and coding changes you may be leaving a lot of money uncollected. Not since the mid 90’s have cardiology seen such significant coding and billing changes as have been put in place in 2009. Across the board the average Medicare fee increased just 1.1 percent. Cardiology in general fared worse than average, experiencing an average decrease of 2% due primarily to decreases in payments for in-office imaging. Keep in mind the 2% reduction is an average number. Some practices will be well above this (especially heavy users of echo services) and others will actually see fee increases.
Here are examples of some of the upcoming changes:
- Sweeping changes in the codes for following up on implanted devices (sweeping as in all of the old codes are gone and the new ones have significant differences). The new codes include such things as specific codes or internet (remote) device checks, codes for devices with leads in 3 chambers, ICM device follow-up codes, and codes for per procedural checks.
- 30 and 90 day global periods are now in place for follow-up for some devices. Also, the new codes are specific to either an interrogation evaluation or a programming evaluation. The codes are no longer dependent on whether reprogramming occurred.
- Wearable cardiac telemetry devices (for instance Cardio net type service) now have specific codes. You no longer bill with an unlisted code. These new codes include the complication of global periods.
- Codes that bundle multiple echo services under a single code have been introduced. Examples include a single CPT for bundling an echo with both a Doppler and color flow and a stress echo CPT that bundles both the stress test and stress echo.
As the examples above demonstrate, the magnitude of this year’s cardiology billing changes is more significant that has been seen in recent years. Without proper education, cardiology billing training, software upgrades and billing resources cardiology practices may see marked reductions in collections and increases in AR.
Staffing
Based on the experience of Cardiology Billing Partners there are four key elements to creating a world-class billing staff:
Recruit, train and retain the best billing staff:
The leading billing organizations recruit best staff. A dedicated, specialized HR team evaluates applicants—applicants must pass a proprietary billing testing process assessing both skill and will. This process shouldn’t be different from the recruiting process of a Fortune 500 organization. The leading billing organizations train to develop desired quality. Junior staff members must pass demanding training programs—junior team members are developed into billers, capable of following the measured and monitored billing process. In addition, staff is trained throughout the year in latest payer rules, follow-up techniques and compliance guidelines. A dedicated Compliance Officer is responsible for all additional HIPAA and OIG training. Best staff is retained; weak staff released. The billing organizations staff is evaluated every year to assure proper development and progress. Evaluations are based on tangible, measurable targets and quality indicators. Best performers are properly rewarded and lowest 10% of performers are asked to leave. This should be done methodically in an effort to continuously improve the quality of billing staff.
Specialization of the billing team: The top billing organizations’ billing team is composed of dedicated specialists in demographic data entry, charge posting, follow up, and patient collections. Each position is designed to excel in its role and is properly supervised and incentivized. Provide the staff with solid analytics support; Besides providing the clients with continuous practice analytics focused on clients’ practice improvements (coding, contracting, profitability, marketing, etc) , the leading billing organizations’ Analytics Group should offer strong analytics support to the billing staff. The Analytics Group should trend and measure payers response times, rejection trends, payment rates ,etc in order to properly focus the billing staff. They should also measure various elements of the internal billing process for continuous improvements. Incentives for billing staff: All positions in billing process are monitored and incentivized to perform optimally for your account. The incentive system while highly motivating for the staff, falls within the parameters established by the OIG for an acceptable incentive system in a medical billing environment. The best performers should be rewarded accordingly.

Outsourcing
One of the key advantages of billing outsourcing is the clear alignment of incentives between the practice and the billing company. The billing company only gets paid when the practice gets paid while the practice’s staff gets paid irrespective of results. There is also an incentive for the billing company to perform better—the better it performs the more it collects for the practice and in turn the more it earns (and vice versa). This is not true for in-house staff whose wages are fixed irrespective of performance and quality of work. This issue, however, is often not fully understood or appreciated by many providers. These providers frequently say: “the staff works directly for me in my office-- they are more loyal and will do a better job and I can see what they are doing”. From our experience, this is simply not true. I recently spoke with a partner at a busy cardiology practice. While one of the billers was out sick, some paperwork was required and the supervisor went out looking for it. When the supervisor opened the missing biller’s desk, a stack of unfiled, old claims was also discovered. It turned out about $40,000 of them were past timely filling deadlines. They were lost. I repeat—the practice lost $40,000! When the biller returned from her leave, she was “sternly” reprimanded. Let me say it one more time—she was reprimanded. No: not fired, but reprimanded. Either way, the practice lost $40,000 in just this one instance alone. When I asked the doctor why a more severe action was not taken, he explained to me that "we already have staffing problems and did not want to alienate the billing staff any further.” The guilty biller was apparently moved to the front-desk role and is now responsible for gathering demographic information and money. I also asked how it was possible that the billing supervisor missed that $40,000. Did they not reconcile charges and payments and track charges, payments and write-offs? To this the doctor replied that “their system did not provide this level of reporting and no such reports were ever given to him”. Since, the practice was using a new release of a major billing software, I know this system has such capabilities—it is just that either (1) no one knows how to use the system—that’s bad or (2) they just don’t want to bother—that’s’ worse! Just imagine how much money is probably lost there annually. At Cardiology Billing Partners we deal with these issues methodically and comprehensively: All the charges, payments and write-offs are visible to you. We track everything so no charges (batches, days or places of service, etc) can be missed.
If we have your charges and do not submit them properly--- Cardiology Billing Partners will reimburse your practice for what you would have been paid by the payers based on your allowable. What this means is that you never suffer financially if we drop the ball. Try to have your billers reimburse you if they drop the ball. Cardiology Billing Partners also provide clients with access to our system so that they can see real time status of their account. We will give you client portal access to reports and dashboard functionality 24/7. At any time, you or your practice manager can go in and check status of claims, payments, patient balances, etc. No more excuses that “the system cannot do this”! We often hear from the physicians how hard and long they work for ever decreasing reimbursements. All this is true. However, too often we also see practices (through various reasons) hurt themselves financially—over and over again. No—your staff will not work harder for you just because you employ them; and no- the biller who lost you $40,000 will not do any better job collecting money and gathering information from patients. You will probably need to “sternly” reprimand them again. A high performing cardiology medical billing company with complete transparency and full alignment of incentives is the surest path to medical billing excellence and strong financial performance for your cardiology practice.

Women’s Health: 5 Things You Can Do to Prevent Cancer

Cancer is something that a lot of people worry about getting. If cancer is found at an early stage, then it can be taken care of. However, cancer can spread around the body, and thus, the best way to get rid of cancer is to not get it. Today we are going to talk about the five things that you should do that can help you avoid getting cancer all together. These things can help keep you safe and help keep you healthy for a long time to come.

First of all, to avoid getting cancer, you need to avoid using any kind of tobacco product. As we all already know, tobacco can cause a lot of health problems, one of which is cancer. You need to do your part in avoiding tobacco to help avoid the chance that you will ever get cancer. This is one of the most important things that you can do to avoid getting cancer. Although it may sound like it’s just a small step in preventing cancer, it is actually one of the biggest. Remember that any kind of tobacco can put you on the course to getting cancer.

The next big way to avoid getting cancer is to watch what you eat. There are certain things that you can do that the American Cancer Society recommends to help keep from getting cancer. First, make sure that you eat five or more servings of fruits or vegetables each day. Things that are whole grain are always best for you and can really help you avoid getting cancer. You can also try eating beans, which are said to help avoid cancer as well.

Try to limit the amount of fat that you take in. When you eat meat, try eating learner meat. This can help you avoid getting cancer in your colon, stomach and other places. Last, try to only drink alcohol in moderation. They say that a little bit of alcohol can actually help you in some ways. However, drinking too much can actually cause problems down the road.

Next, you have to shoot for maintaining a healthy weight. This can be done by exercising regularly and, of course, not overeating. Try to mix up your diet, because eating a lot of meat and nothing else can increase your risk of getting cancer. It is very important that you eat your meat (because the body needs it), but also eat other things that can help keep your system clean.

Last, but not least, is skin cancer. Another way to avoid getting cancer is to avoid getting skin cancer. You can do this by protecting your skin from the sun. The sun is the number one cause of skin cancer in the world, but not the only one. You also need to avoid repeat exposure to x-rays and, of course, certain chemicals that can cause skin cancer as well. Following these steps can really help you to avoid getting cancer, and that is what this whole talk was about, helping you to keep your body safe from cancer.