Is Now A Good Time To Start A Medical Billing Business?

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We are asked this question quite often and our response is always a resounding “Yes!”  There are always things that affect medical billing but none of them (so far) have changed the need for medical billing services.  The passing of the Affordable Care Act (commonly known as Obamacare) is just one of these recent changes.  Many people have wondered if the ACA would make billing services go out of business.  On the contrary.  Now more than ever, billing services are needed.  While the Affordable Health Care Act has definitely influenced the field of medical billing, it has not decreased the need for educated medical billers.  The key word in that last sentence is educated.  Doctors need experienced, informed people handling their billing.
Many of these ACA plans have very high out of pocket expenses.  Gone are the days where the provider can simply rely on the amount they receive from the insurance carrier and not worry so much about collecting the patient’s portion (although that was never a good idea – we do know many offices that had that mentality).   It is important that the person doing the billing is on top of ALL billing, including patient billing.  Many providers who do the billing in house lose money because:

1.  They hire people to do the billing but really don’t know what is happening in that area.  They are only aware of the bottom line – did the practice bring in enough money to cover all of the expenses and pay the doctor a little.  They don’t know:

a.  how much they billed out

b.  how much was received

c.  how much is still outstanding

d.  are denials being handled

e.  are the aging reports being worked

f.  are the patients being billed

g.  how much is being written off

2.  Often there is a lot of turnover in the provider’s office.  This can result in poor training.  Did the previous person leave unexpectedly?   Does anyone still working at the provider’s office know the job?

3.  Many times the biller in the office has many other duties as well including checking in patients, answering phones and cleaning the bathroom.  Go ahead and laugh but we know it’s true.  Often times the job of billing gets pushed to the bottom of the ‘to do’ list.  Not because it isn’t important but because it can.

4.  A provider may think that their biller knows what they are doing, but do they really?  How can the provider be sure?  Do they keep up with all of the changes?

This is why billing services are still a very good business opportunity.  As we have always said, it is no “get rich quick” scheme.  It is hard work but it is a needed field.  It is also so important to keep up with changes.  Whether they are big or small they affect the income.  It is increasingly difficult for a small provider to keep up with the expenses of a medical practice.  They must find better ways to keep the income steady and maximize their receivables.  Larger practices must make sure that money is not slipping through the cracks since they have so many higher expenses.  Outsourcing to a billing service can be a smart move for both the small and larger offices.



If you are considering starting a medical billing service but don’t know where to begin, check out our online medical billing courses.

Marketing Your Medical Billing Business

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Marketing your medical billing business can be the hardest part of succeeding in this industry.  Without clients you can’t stay in business.  But how do you get them when you are just starting out?  It’s a problem that has plagued many medical billing businesses and is the most common reason why most of the ones that don’t make it, fail.


So where do you start?  What do you do?  What really works?


Well, unfortunately these questions do not have simple answers.  What works for one doesn’t always work for others.  A method may work one time, but then not work again.  The important thing is that you have a plan.


1.   Determine how much money you have to spend on marketing

2.  Determine which methods of marketing you want to try that fit into your budget and your personality

3.  Decide what you are going to do and when you are going to do it  (it’s important to give yourself a time table for doing the marketing)

4.  Track your efforts

5.  Follow up


Marketing comes easier to some than to others.  If marketing is a struggle for you don’t get discouraged.  Break it down into small tasks and then it will not seem so hard.  It is also easier if you get a little help.  Connect with others that have already gone through this or are going through it now.


For more information on Marketing your Medical Billing Business visit our online course Marketing A Medical Billing Business   We offer our students full support.

Subscriber VS Patient – Avoid Denials

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Many offices do not recognize the importance of including subscriber information on the claim form. They often will simply list the patient as the subscriber even if they are a dependent. This can cause many issues including outright denials of services. Some insurance carriers process the charges against the wrong patient when the patient is not listed correctly as a dependent. Others will deny stating that the information on the claim does not match the records. Excellus BCBS of Utica recently sent out a provider bulletin advising providers that effective 12/1/2014 they will begin rejecting any claim that does not have the proper subscriber information listed on the claim. Since we are in this area we know of many providers offices that will be affected. When patients come in for services, the information about who the insurance is through (the subscriber) should be obtained. The person’s name, subscriber id and date of birth are required on the claim form. Without this information providers may find that claims will be denied.


For more information about insurance billing visit

Coding Questions and Answers

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Q.  If we cannot find a CPT code that exactly describes the procedure done, can we bill a code that closely describes the procedure?

A.  If a service is performed for which you cannot find a CPT code, it is always best to use an unlisted procedure code rather than the closest possible code. Within the CPT book are a number of specific codes that have been designated for reporting unlisted procedures. They are listed at the end of each section. By billing a code that was not performed completely, it may be interpreted as fraud because it involves billing for services that were not performed.

Q. What is the site of service differential and how does it affect reimbursement?

A. There is a listing of procedures that are most often performed in a physician’s office. If these services are provided in another location, such as in a hospital outpatient setting, payment for these services is reduced.

Q. Is there a difference between a copayment and coinsurance?

A. People often use these two terms interchangeably. However, there is a difference. A “copayment” (or copay) is the out-of-pocket expense to the patient at the time of service, usually $10, $10, or $25, and is common with an HMO-type insurance plan. “Coinsurance” refers to the patient’s out-of-pocket expense after the insurance has paid its liability in a traditional health insurance plan. For example, if a patient has such a plan that pays 80 percent after their calendar year deductible, the patient’s coinsurance would be 20 percent. This is the amount the patient is responsible for and can be collected by the physician’s office either at the time services are rendered or after the insurance has paid its percentage of covered charges.

Q. Can I just look up ICD-9 codes in Volume 2, the Alphabetic Index? What is the purpose of Volume 1, the Tabular section?

A. You should never code directly from the Index. Fifth digits are often omitted from the Index entries. You should always confirm a code from the Index by looking it up in the Tabular section. The Tabular section contains additional instructions, Includes and Excludes notes, flags that indicate when a 4th and 5th digit is required, and other valuable information that will aid you in proper code selection. Depending on just the Index for code selection is to invite error.

Q. We had a claim denied due to “concurrent care.” What does this mean and how do we handle this?

A. Concurrent care is when a patient is being treated by two different providers for different problems at the same time. For example, a patient may be hospitalized by a general surgeon for an operation and may also be seen while hospitalized by a cardiologist for an unrelated cardiac condition. Frequently claims will be denied as a duplication of services when the patient was seen by two physicians on the same day when no duplication actually occurred. Each claim must have a different ICD-9 code for the services provided by each physician, which support and justify the need for the services provided.

Q.  I am having trouble getting a commercial insurance carrier to pay on a claim. Any suggestions?

A. You might want to try getting the patient involved. The insurance contract is between the insurance carrier and the patient. The provider is an outside party. If you are not getting a response from an insurance carrier on an unpaid claim, let the patient know you are having a problem and ask them to contact the insurance carrier. In many cases, this will result in a quick resolution of the problem.

For more information about Medical Billing and Coding visit our online course for Understanding Coding and Modifiers
For more online courses visit our complete Online Medical Billing Study Course

Modifier -59 clarification

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Modifier-59 is often used incorrectly in coding procedures. Therefore,  CMS has established four new HCPCS modifiers that are to define specific subsets of the -59 modifier.


They are:

XE Separate Encounter- A service that is distinct because it occurred during a separate encounter

XS Separate Structure-A service that is distinct because it was performed on a Separate Organ/Structure

XP Separate Practitioner- A service that is distinct because it was performed by a different practitioner

XU Unusual Non-Overlapping Service- The use of a service that is distinct  because it does not overlap usual components of the main service.


These additional modifiers go into effect on January 5, 2015.


There are many in the medical billing industry that are still confused as to when to use these modifiers. These new modifiers are not consistent with some of the coding regulations  (example: dermatologists are BIG users of modifier 59 because they frequently perform procedures on different unrelated lesions and sites.  There about 49,000+ CCI bundles that affect dermatology). Since we have a few more months for implementation, we are looking for an easier explanation with examples to share with you and will be updating this as we learn more. Stay tuned!!


For further information about coding see our course at:

CMS Open Payments (the Sunshine Act)

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Did you receive this email within the last few days?
7 Days Remain to Review Your Data Before it Goes Public
What does it mean and whom does it affect?
If you are a billing service, you may have received this on behalf of your providers.
As of the end of September, 2014, CMS will make public monies received by physicians and hospitals from manufacturers and group purchasing organizations. As an example; an orthopedist uses just one manufacturer’s prosthetic for hip replacements. The orthopedist has convinced the purchasing department of the hospital to only purchase from this one company. The manufacturer has paid the orthopedist a sum of money for making this arrangement. This will now be made public. An ophthalmologist writes a paper about a new technique for cataract surgery mentioning a certain manufacturer. Previously, the surgeon had to state that a payment had been made by the manufacturer. Now, this information will be made public for anyone including the amount paid for the endorsement.
CMS has given all entities that will be affected by this new disclosure until September 11,2014 to review the information before it is released.
For more detailed information, check out the Open Payments User Guide
For more information about billing Medicare see our online course: Billing Medicare, TRICARE, and Medicaid

Chiropractic Maintenance Not Covered by Medicare

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Chiropractic Maintenance Therapy Not Covered


To meet Medicare coverage criteria, chiropractic treatment should be aimed at treating acute injuries, re-injuries, or exacerbations. The result of chiropractic manipulations is expected to be an achievable improvement and with a clearly defined end point. Once the maximum therapeutic benefit has been achieved for a given condition, ongoing maintenance therapy is not considered medically necessary under the Medicare program.

Maintenance therapy is defined by Medicare as a treatment plan that seeks to prevent disease, promote health, and prolong and enhance the quality of life, or therapy that is performed to maintain or prevent deterioration of a chronic condition. Therefore, Medicare does not cover maintenance therapy. For additional clarification of the coverage criteria for chiropractic services, refer to your MAC’s Local Medical Review Policy.


Medicare Eliminates 2% Reduction on Chiropractic Services Effective July 1 2014

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The Centers for Medicare & Medicaid Services announced that they have eliminated the 2% reduction for cpt codes 98940, 98941, & 98942. This elimination of the 2% reduction is effective for all services on or after July 1, 2014. This 2% reduction was implemented following a demonstration required by the Medicare Modernization Act. The costs of the demonstration were higher than originally anticipated. CMS implemented a policy to recoup the expenditures from the demonstration in the form of a 2% reduction for cpt codes 98940, 98941 & 98942 over a five year period from 2010 through 2014. The Office of the Actuary has determined that the expenses were recouped by the end of the first half of 2014. Therefore, the July update eliminates the 2 percent reduction.


For more information on billing Medicare visit our course: Billing Medicare, TRICARE, and Medicaid

Denials – Make sure all claims affected are corrected and resubmitted

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Not all insurance claims that are submitted to insurance carriers are paid on the first submission. This is one of the reasons that we always say “Medical billing is much more than a data entry position.” A certain percentage of submitted claims will be denied. That percentage will vary depending on the office submitting the claims.


Offices with good billing systems in place will have a lower percentage of denials. Also, having a good system for patient verification will also help reduce the number of denials. Lowering the amount of denials on initial claims is good, but it is also important to make sure that any denials are handled quickly to prevent loss of revenue.


One thing that tends to get overlooked when handling denials is to check for other outstanding claims on a patient when a denial is received that will affect all claims out on a patient. For example, if a denial is received for a patient because the patient’s insurance has changed then all claims submitted for that patient after the change of insurance will need to be corrected.


Many times a biller will receive a denial for one particular date of service, make the correction and resubmit just that claim. They don’t take the time to look and see if there are any other claims out for the patient that also need correcting. As I’m writing this I’m thinking it would be a no brainer, but in all of my years of training this is actually something that needs to be taught especially with new or inexperienced billers. They just don’t think about the whole picture without being taught to.


We also teach them to look at the other family members as well. If the insurance changed for one of the children and the policy is through the parent, it most likely changed for everybody in the family. Looking into it now can save much work later on and even prevent money from being lost.


If the denial is for something that is only specifically related to the claim in question then this is not an issue. But if the denial is for something that would affect all claims for the patient and/or family, then it is important that the biller take the time to make sure all claims are corrected and resubmitted and not just the one that received the denial.


For more information on Handling Denials see our online course:
Reading EOBs, Handling Denials & Filing Appeals Course

Are you violating HIPAA with your emails?

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Email is such a prevalent form of communication in the medical office today we must be careful that we are not violating HIPAA laws. Many people use email as their main source of communication, even in the same offices. In our billing office we very often will send emails to each other, even if we sit in the same proximity. It is simply more convenient. Often one of my workers will say to me “can you please do ….” or “Dr xxx needs ….”. Most times I respond with “send me an email.” It is easier for me to make sure it gets done if I have something in writing. If someone mentions it to me while I am in the office it may be long gone before I get back to my desk.


Most people do not have secure email. If not using secure email it is crucial that you do not include any PHI in your communication. So is it necessary to always use secure email. Not necessarily. It is just important that you do not include PHI in the email. When we communicate with a provider and it is necessary to mention a patient we use some sort of code such as an internal chart number or just a couple of initials of the patient’s name. A good question to ask is “if someone were to intercept this email would they be able to identify who I am talking about?” If the answer is no you should be ok.


Here is an example of an unacceptable email:

“Dr Jones,

Mary Johnson came in today to get the results of her pap smear. I told her you needed to speak to her about the abnormal results. Please call her at her home number in the PM system.”


Here would be an OK way to send the same information:

“Dr Jones,

Patient MJ, chart # 52633 came in today to get her test results. I told her you needed to speak to her regarding the results. Please call her at her home number in the PM system.”


If it is necessary to send PHI then secure email should be used. You can either use a password protected email or an encrypted email.


More information on HIPAA and other Regulatory Issues. Information on other Online Medical Billing Courses.