Physician Billing

Written by Kimberly Clark
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In the vast world of healthcare, there are government healthcare organizations and commercial healthcare companies. Moreover, within these two entities there are payers and providers of services. The payers are the organizations or businesses that are responsible for approving and ultimately paying the physicians for the medical services that they have already provided to the patients.

Examples of government healthcare payers are Medicare, Medicaid and CHAMPUS (Civilian Health and Medical Programs of the Uniformed Services). Private healthcare payers are health insurance companies such as Blue Cross/Blue Shield, Cigna, or Aetna. In addition, there are also health plans such as those offered through an HMO (health maintenance organization).

The fact that most medical services are not fully paid for until well after they have been performed certainly sets the healthcare industry apart from most other sectors of business. Imagine how difficult it would be for a barber to collect for his services 30 to 40 days after he cut someone's hair. This alone would be reason enough to employ a specialist versed in physician billing, but unfortunately there are many other nuances that have to be dealt with when attempting to bill a payer for a physician's services.

Submitting Medical Claims

Federal regulations have instituted standards for submitting medical claims. All claims submitted should be "clean," meaning they conform to the standards mandated by HIPAA (Health Insurance Portability & Accountability Act of 1996). They must also be itemized by diagnosis and procedural code as set forth by the International Classifications of Diseases 9th Edition (ICD-9) and the Current Procedural Terminology, 4th Edition (CPT-4)manuals, respectively. And lastly, they need to be electronically transmitted to the payer. Because of all this, comprehensive software systems are becoming more and more popular, with those that offer multi-faceted solutions being the best options.


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