- There is a difference between an EMR and an EHR
Both EMR and EHR are digital records of patient health information.
But one is more limited than the other: An EMR is more like a chart of the patient’s health information. An EMR is something like this but it is only accessible by one physician. Only physicians who can have access to the office can view those records and they cannot be shared with any other physicians outside of his/her Office.
An EHR is different as it contains the patient’s records from multiple doctors and provides a more holistic, long-term view of a patient’s health. This includes their demographics, test results, medical history, history of present illness (HPI), and medications. A clinic, hospital, physician, or organization would use EHR because it allows them to not only follow the patient’s entire history from specialty to specialty, but it also allows them to pull the data into a claim for billing charges to the patient’s insurance carrier. EHRs are more robust than EMR.
- Rejections and Denials are not the same things.
Rejections come from the clearinghouse and never cross over to the insurance carrier. They are quickly bounced back to the provider to amend the claim. Most rejections happen when there is an error due to missing information or incorrect information on an electronic claim. Rejections can also occur when the information provided by the clearinghouse, does not match what the payer has on file.
Example of a clearinghouse or EDI rejection: ACKNOWLEDGEMENT/R
EJECTED FOR INVALID
INFORMATION
PROCEDURE CODEXXXXX MODIFIER(S)- XX
SVC Line Response Procedure Code
Modifier(s) for Service(s)
Rendered PROCEDURE
This rejection indicates that there is an issue with the procedure code/ modifier combination billed out on the claim.
Denial’s come from the insurance carrier after the claims have passed through the clearinghouse and usually take a little longer to be received back to the billing office.
Example of a denial:
Prior Authorization was not obtained.
- Everything rolls downhill right into your lap:
Yep! That’s how the cookie crumbles. It doesn’t make a difference if the registration or the appointment desk forgot to get the patient’s correct address or date of birth. Once it is rejected or denied, it becomes your responsibility to get it corrected, especially if you don’t want the hold time on the claim to be exceeded. Sending work back to the front -end personnel can cause a claim to be denied because it is past the filing time limit, depending on the payer. This is why it is beneficial to know your payer filing time guidelines. If A/R days for your claims are lagging, it is up to you to prove why they are lagging.
- You must be tenacious.
I can’t tell you how being tenacious has served me so well.
Tenacity and perseverance are necessary to assure timely payment during the billing process. For me, this entailed using all contacts and research avenues available to get my answer. But this was all done while maintaining HIPPA guidelines. There will be times when you will have to call the insurance carrier multiple times until you get a knowledgeable person, who can tell you exactly what’s wrong with the claim and how to fix it. Sometimes you might even have to request to speak to a supervisor. Whatever it is make sure you are always tenacious with a friendly voice and a smile. Be understanding but know when to push and escalate the matter.
- You have to be a relationship builder
Customer Service and a friendly attitude are a big plus in Medical Billing. Why? Because you deal with all types of people. Being able to speak to people who are ill, stressed, or having a bad day while leaving them feeling like you care is a special thing. Having this ability is invaluable when you are dealing with insurance representatives. Some of the key steps to providing great customer service in medical billing are as follows:
1) Ask the right questions. Also, have a pleasant voice and a smile.
2) Be a good listener. Listening and understanding will allow people to open up to you and they will be more willing to help you by giving you all of the information you want and need. The person may even provide you with a direct call number. Now that’s sweet!
- Know how to manage your time.
As a medical biller, you have to keep track of payer filing time limits when running your monthly reports. Be mindful of when is the best time to follow up on the status of your claims. Checking the portal for Clearinghouse /EDI rejections etc.… Keeping track of your time is critical to making sure your claims are paid in a timely manner and that you always know where your A/R is and how long it has been sitting. It also helps you to answer pertinent questions your manager or provider may have when it comes to your A/R.
