In this hastily developing healthcare setting around the US, employers need trained professionals to help them manage the inevitability of changes, maintain compliance, and preserve profitability. Billing is a complicated matter that only trained and skilled people can do. Its importance is often overlooked most especially in the healthcare industry as professionals in this field tend to focus on giving proper care and services to the patients that is why administrative tasks like this are not their priority. This happens most likely to midwives and other birth professionals. Some individual practice owners don’t have enough time to crawl out keeping track of all the records, collecting payments, managing cash flows. Hence, a medical biller is the one that can save the day.
A medical biller is a trained professional who submits bills to patients and/or health insurance companies and follows up to make sure the healthcare provider receives payment for the services. When the medical biller receives a claim for the healthcare services, it’s represented by a code, and it’s the medical biller who translates it into a claim. It’s the medical biller’s responsibility to follow up on the bill until the provider has the final reimbursement. Like any other profession, Medical Billers are compensated well. As they perform crucial tasks, they are paid more. On average, medical coders (certified and non-certified) make $54,797 annually. Medical billers and coders without certification earn approximately $47,200 per year while certified coding and billing specialists make an average annual salary of $60,097 — 27% more than their non-certified colleagues. The Medical Coding and Billing Salary Survey demonstrates once again that certification pays. The average salary for professional coders with two credentials rises to $64,712. Billing and coding specialists with three or more credentials earn approximately $69,942 per year. In addition to competitive salaries and standard employment benefits, many employers also offer paid professional association dues and paid continuing education. Full or partial coverage of continuing education is particularly valuable, given the correlation between salary and medical coding credentials. Other variables that weigh into the salary equation include experience, specialty/medical field, employer type, and location. The price you pay for a biller varies greatly from hourly rate, commission, scope of work specific charges, or salaried. When determining if the price is fair for the services, determine the return on investment that cost if bringing in to your practice. If this biller is really good and brings you in far more money for a quicker reimbursement time, paying them more makes a lot of sense to do. Hiring the experts and the national bests will costs you more, but get you far better results in the end. References Aapc. (2022, February 9). Medical coding salary survey. AAPC. Retrieved August 5, 2022, from https://www.aapc.com/resources/research/medical-coding-salary-survey/ Pettigrew. (2021, May 7). The growing importance and value of medical billing services. PETTIGREW. Retrieved August 5, 2022, from https://www.pettigrewmedical.com/the-growing-importance-and-value-of-medical-billing-services/ What is a medical biller? The Best Health Degrees. (2022, April 25). Retrieved August 6, 2022, from https://www.besthealthdegrees.com/faq/what-is-a-medical-biller/ Medical billing is a series of complicated matters that requires enormous amounts of effort and understanding to perform. It contains different codes and descriptions that are intended to determine and facilitate payment and collection to keep your practice operational.
If you're aiming to dig into medical billing, whether you want to add it onto your skills or if you decide to hire an expert in medical billing, it is important to understand the nature of the job in different types of facilities. In the medical and midwifery world, codes work differently. Countless codes that need to be updated from time to time. There are ICD Codes, CPT Codes, HCPCS Codes, DRG Codes, Modifiers, etc. Each code has different usage and transcriptions that are used and designed within specific diagnostics. In this article, we will be discussing how professional fee and facility CPT codes differ from each other. Professional and facility coding describe two very diverse aspects of the healthcare industry. Simply speaking, professional fee coding is the billing for the physicians and the experts. The facility coding is billing for the facility and the equipment. Professional codes primarily capture the complexity and intensity of provider care provided during a visit, facility codes detail the volume and intensity of hospital or health system resources used to deliver patient care, such as the use of medical equipment, medication, and nursing staff. What is a Professional Fee Code? Professional fee, refers to coding and billing the physician side of a patient encounter. Professional fee coding covers the work performed by the provider and the reimbursement they will receive for the medical services performed. In general, midwives and midwife-led birth centers offer standard pregnancy care packages. This package covers the professional fee, all prenatal visits, labor and delivery care in a birth center, at home, or in a hospital, birth kits, newborn care and assessment, postnatal visits at two and six weeks postpartum, and phone consultations. On average, a midwife's basic maternity care package ranges from $3,000 to $6,000 for normal low-risk pregnancies. This can vary depending on the location or state where your practice is located. The basic package cost usually comprises prenatal visits, labor and delivery care, and postnatal visits. To know more about midwifery reimbursement rates, here is a sample professional fee for CNMs and CMS MEDICAID FEE-FOR-SERVICE REIMBURSEMENT RATES FOR CNMs and CMs as of September 2013 What is the Facility Fee Code? A facility fee is a charge that you may have to pay when you see a physician or a midwife at a clinic that is not owned by that physician or midwife. Facility fees are charged in addition to any other charges for the visit. Facility fees are often charged at clinics that are owned by hospitals to cover the costs of maintaining that facility Hospitals, hospital-based facilities (such as outpatient clinics owned by a hospital), and various other medical facilities often charge a facility fee as well as the provider's professional fees. CMS regulations do not establish a general definition of “facility fee,” but CMS sets reimbursement rates for these fees subject to various requirements set forth below. The facility fee covers overhead costs, such as equipment, space, and support staff. This fee is sometimes referred to as the technical component of the bill. Under the CMS “provider-based status” rules, Medicare will reimburse for facility fees at a hospital-based facility (such a group practice owned by the hospital) meeting certain requirements but not at providers' offices not affiliated with a hospital. A facility or practice has provider-based status and thus can bill for facility fees it if has a relationship with the main provider (i.e., the hospital) concerning a range of issues, such as licensure, clinical and financial integration with the hospital, public awareness, and billing practices. The regulations specify payment recovery procedures if a hospital inappropriately treats a facility as provider-based. Facility Claim A single facility claim is submitted for all services provided to the patient on that date. ● Condition code is submitted in the claim header, letting the payer know that the evaluation and management (E/M) codes are distinct, potentially reimbursable services, and not duplicates. ● The occurrence code and occurrence date at the header level indicates some of the services were related to an accident, which lets the payer know other medical coverage may apply for the services on the claim. ● Revenue codes indicate the facility department or area ● HCPCS Level II/CPT® codes ● Diagnosis codes appear at the header level, not tied to a particular line In order to bill the facility fees, the hospital or facility like a birth center should already have criteria for the codes they use. The Centers for Medicare and Medicaid Services does not specify these criteria, but expects them to form a bell-shaped curve. If the hospital has not established these guidelines, they could use and modify the suggestions published by the American College of Emergency Physicians, available at https://www.acep.org/administration/reimbursement/ed-facility-level-coding-guidelines/ Also visit https://www.ashp.org/-/media/assets/pharmacy-practice/resource-centers/ambulatory-care/Facility-Billing.pdf Your practice will rely mainly on your cash flow. Professional fees and facility fees are the top two revenue streams of your business. Your clients must pay you with your expertise same with the facility you have been using to provide quality of service. As a practice owner, if you happen to create a unique system that collects these two types of fees and utilize it methodically, then you are on the right track and that is for sure. References Renee Dustman. (2015, February 1). Compare and contrast physician and outpatient facility coding. AAPC Knowledge Center. Retrieved August 6, 2022, from https://www.aapc.com/blog/29346-compare-and-contrast-physician-and-outpatient-facility-coding/ James Orlando, A. A. (n.d.). Facility fees and Accountable Care Organizations. Retrieved August 6, 2022, from https://www.cga.ct.gov/2014/rpt/2014-R-0238.htm Understanding facility fees - the Alliance. (n.d.). Retrieved August 6, 2022, from https://the-alliance.org/wp-content/uploads/2021/05/TheAlliance_FacilityFees2021_EE_UnderstadningFees_6152021.pdf One of the most common mistakes in medical billing is the failure of accurate verification of insurance claims. Insurance verification is the topmost significant step in the medical billing and coding process. Before you provide midwifery care to your clients, you have to verify if the patient’s healthcare benefits will cover up all the medical procedures needed. Presently, the healthcare industry continues to shift into many complex settings that require closer attention in validating insurance coverage, patient benefits, deductibles and copayments.
Every successful billing merely depends on the success of eligibility verification. In a brief summary, health insurance verification is the process of checking a patient’s active coverage with the insurance company. It also verifies the eligibility of a patient's insurance claims. Checking your patient's insurance benefits BEFORE the patient is seen should be a fundamental part of your practice's administrative process. Otherwise, you run the risk of claims being denied and left unpaid. You don't always have the right to appeal or bill your patient which is why it is so important to know the patient's insurance benefits before treatment begins. When checking benefits, be sure to ask the right questions. 1. What is the patient's financial responsibility?
2. Does this patient have visit limits?
3. "Is this a plan year or calendar year?"
4. "Is a referral or authorization required?"
If your administrative process does not include checking patient benefits before the patient is seen, your revenue cycle management is hindered from the start. Accurate insurance verification ensures a higher number of clean claims which speeds up approval and results in a faster billing cycle. Inadequate verification of eligibility and plan-specific benefits puts healthcare organizations at risk for claim rejections, denials, and bad debt. Always pay attention to the documents submitted and be scrupulous in receiving the data needed for your service reimbursement. Reference Ramsey, D. (n.d.). The 5 most important questions to ask when checking benefits. Account Matters Blog. Retrieved August 5, 2022, from https://blog.accountmattersma.com/5-important-questions-to-ask-when-checking-benefits If you are a midwife running a private practice, you know that billing and insurance claims can be a major hassle. Not only is it time-consuming, but it can also be very confusing. It can even distract you from patient care. This is why many medical practices are outsourcing their medical billing. Outsourcing can save you time and money, and it can also help improve your bottom line. In this blog post, we will discuss 15 reasons why you should outsource your medical billing.
1. Time SavingsOne of the biggest reasons to outsource your medical billing is time. When you outsource your medical billing, you can free up time that you would normally spend on billing and insurance claims. This extra time can be used to see more patients, work on other aspects of your practice, or take a much-needed break! 2. Money SavingsAnother great reason to outsource your medical billing is for the money savings. When you outsource your medical billing, you can save money on office staff costs, office space, and supplies. You can also save money on medical billing software and hardware because the medical billing company will take care of that. Outsourcing medical billing services can also help you save money on collections. When you outsource your medical billing, you can have a team of experts from the medical billing company working on collecting so that you can focus on seeing patients. 3. Improved Bottom LineOutsourcing medical billing services can improve your financial performance. This is because a medical billing service can help you save money on in house employees and overhead expenses. In addition to these reduced costs, outsourcing medical billing can help you get paid faster! How? When you hire medical billing services, you can take advantage of the latest technology and software and their revenue cycle management expertise. This means that your claims will be processed faster, you will get paid sooner, and your cash flow will be stable. 4. Reduced StressOne of the best reasons to hire medical billing services is for the reduced stress. When you outsource your medical billing, you can rest assured that your billing and insurance claims are being handled by a team of professionals from a medical billing company. This can take a lot of the stress off of you and allow you to focus on seeing clients. 5. Increased AccuracyUsing an in house billing team can result in more billing errors because your staff may not be as experienced or may not have the time to focus on billing. When you outsource your medical billing, you can increase the accuracy of your billing and insurance claims. This is because you will have a team of experts from the medical billing company working on your claims. They will make sure that all of the information is correct and that your claims are filed correctly. This can help you avoid billing errors and save you a lot of time and money in the long run. 6. TimelinessAnother great reason to outsource your medical billing is for the timeliness. Medical billing services use the latest technology and software, so choosing to outsource billing means that your claims will be processed faster and you will get paid in a timely manner. 7. Easier Access to Billing and Insurance InformationWhen you outsource your medical billing, you will have easier access to billing and insurance information. This is because the team of medical billing services experts will be handling all of the claims and paperwork for you. This can save you a lot of time when you need to access this information. 8. Reduced Chance of Fraudulent ActivityOutsourced billing services can reduce the chance of fraudulent activity. This is because the outsourced billing team is made up of experts who know the ins and outs of the medical billing process. This outsourced billing team will be handling all of the claims and paperwork for you. They will be able to spot any red flags or suspicious activity. 9. Stay Up-to-Date EffortlesslyOne of the many things that can affect reimbursement is changes in coding. By outsourcing medical billing services, you can be sure that the team of experts from the medical billing company will stay updated on the latest coding changes. This way, you can be assured that your claims will be processed correctly. 10. Continued Support and TrainingOutsourcing medical billing will also allow you to receive support and training. This is because the team of experts will be available to answer any questions that you have on the medical billing process. They will also provide ongoing training so that you can stay updated on the latest changes in the industry. 11. Higher Staff MoraleYour own team can be bogged down by the mundane tasks of billing and insurance claims. This can lead to low morale among your in house staff. When you outsource your medical billing, you can free up your in house team to focus on more important tasks. This can lead to higher morale among your staff and a more positive work environment. 12. More Time to Focus on PatientsWhen you outsource your medical billing, you can focus on providing the best possible care for your patients. This is because outsourced medical billing services will allow you to have more time to spend on patient care and less time spent on billing. This is why medical billing services play such an important role in any midwifery practice 13. Higher Patient SatisfactionPatient satisfaction is important for any healthcare organization. When you outsource your medical billing, you can focus on providing the best possible care for your patients. This can lead to improved patient satisfaction and a better reputation for your organization. 14. Better Use of Your TimeAs a busy midwife, you likely do not have the time to focus on billing and insurance claims. When you outsource your medical billing, you can use your time more efficiently by focusing on other aspects of your practice. Not having to worry about your billing needs can give you more time to focus on your practice’s growth strategy, such as how to gain more revenue, improve your services, and your organization’s success. This can improve your decision making process so you can focus on your key performance indicators and set up your medical practice for success. 15. Increased Income Due to Proper Follow-Ups40% of many midwives' income is due to proper follow-up with the insurance companies. Getting the correct payments is crucial when it comes to billing and your income. Just by simply following proper follow-up procedures you can insure that you will receive the right amount that are due. ConclusionHealthcare is an ever changing industry with increasing demands. Medical billing companies can help you achieve success as you look out for your patients’ interests. There are many reasons why you should outsource your medical billing. Outsourced medical billing can save you time and money so you can focus on treating patients. In this blog post, we discussed reasons why you should outsource your medical billing. It is important to find the right medical billing company that will understand your organization’s specific needs so they can provide a customized solution. Our team of billing experts has the experience and know-how to help you outsource your medical billing so you can focus on what’s important — patient care. If you are considering hiring medical billing services, we encourage you to contact us today! We would be happy to discuss how we can help you save time, save money AND make you more money. https://medicalbillingauthority.com/15-reasons-why-you-should-outsource-your-medical-billing/ Empowering Midwifery Education has an amazing online course for midwives around all the billable services to process with insurance companies. The midwifery billing and coding course is packed with over twelve hours of videos, resources, and tools to help any midwife with setting up billing insurance plan with their private practices. We start with basics of billing and coding like ICD 10 codes, CPT codes, and POS codes typically billed by midwives to insurance companies. There are hours of content about billing in or out of network coverage to plan, how to negotiate with insurance companies, creating financial policies, and outstanding patient balances. So much is covered in this affordable, valuable resource to any midwifery practice. Be one step ahead of the insurance billing curve and take this course to advance your practice to the next level of success!
There are over 15hrs of content available! Enjoy the lifetime access to dive deep into specific professional services that midwives can bill for part of their scope of practice (maternity care, newborn care, gynecological services, well women care, contraception, primary care, & telemedicine). This is by far the most comprehensive billing and coding training for midwives out there! Comprehensive Billing and Coding for Midwives | Empowering Midwifery (teachable.com) When you interview for a medical billing position, you may be asked several questions about your professional experience, industry knowledge, work practices and problem-solving skills.
Knowing what questions to expect can help you prepare answers ahead of time and practice before you meet the hiring manager. In this article, we explore some of the most common questions asked in a medical billing interview to help you get started. Most common medical billing interview questions: When interviewing for medical billing roles, there will be some common ground from job to job, company to company. Here are 10 questions with example answers so you can craft your own effective responses: In what medical billing specialties are you experienced? Medical billing specialties are based on the type of care patients receive from the provider. This question allows you to showcase how your experience meets the needs of the facility. In your answer, outline what patient procedures you've billed for and any that you would like to gain more experience in if applicable. Some specialties include billing for internal medicine, family medicine, anesthesiology, dermatology and neurology. Example: "In my previous role, I did medical billing for an oncology practice, which I had to research and teach myself since it was my first time billing those specialized procedures. Additionally, I also have experience billing for hospitals, family and internal medicine as well as pediatrics." What types of medical records software have you used? Medical billers typically review digital patient files, submit claims through online portals and do most of their work using industry software. When answering this question, list the software you've used in previous roles, how you used it and any training or certifications you've received. If the job description lists a specific software for the role, be sure to address your knowledge of that software, too. Example: "Over the past six years as a medical biller, I've worked with eClinicalWorks as well as CareCloud and Charts EHR. With eClinicalWorks, I monitored claims processing and scrubbing to ensure claims were filed with insurance companies and patients received accurate bills. I also used it to verify patients' insurance information and eligibility. In my last role, I used CareCloud and Charts EHR for revenue cycle management, filing both paper and digital claims and sending bills to patients. With each software, I reviewed the available analytics to track how much we billed, how much had been paid by insurance at any given time and the amounts of outstanding insurance claims." Explain a time when you had to resolve an error with a claim in the clearinghouse. A clearinghouse is an online portal where medical billers submit claims to insurance payers, and part of this process involves payers scrubbing claims and sending back any with inaccuracies. Use this question to demonstrate your knowledge of the clearinghouse and show how you address these rejections. Example: "When there's an error with a claim, that means that the payer has found something wrong with the information we provided. My job as a biller is to review the electronic remittance advice, or ERA, that breaks down each element of the claim and the items that they're denying. I then compare the information in our electronic health records system, or EHR, making sure the patient's name and date of birth are correct, the right amounts are attributed to copay, coinsurance and deductible amounts. I often review physician notes, diagnosis codes and procedure codes to make sure everything is correct. Whenever I find the errors that initially caused the payer to reject the claim, I make sure to correct the information in the EHR system before resubmitting to the clearinghouse. This ensures our in-house records match the payer records." Can you explain the difference between copays, deductibles and coinsurance? These three terms represent the amount of money a payer and a patient pay for care over an insurance contract. This question assesses your knowledge of these important differences since medical billers are responsible for ensuring each amount is correctly charged on a claim. In your answer, give the definitions of each term and explain how you use this information on the job. Example: "A copay is what the insurance requires a patient to pay when they visit. This amount may vary depending on whether the patient sees a general practitioner or a specialist. Coinsurance is any amount of a claim that an insurance payer doesn't pay. Some patients may have supplemental insurance to cover these amounts. Finally, a deductible is the amount that the patient pays out of pocket, in total, for care expenses before the insurance company pays. Knowing the difference between these three terms help me double-check that money is charged toward the right insurance element on the explanation of benefits, or EOB, ensuring patients only pay the amount they have to pay based on their insurance plan." How do you follow HIPAA regulations when managing patient accounts? Every patient must sign a Health Insurance Portability and Accountability Act (HIPAA) form when they see a provider. This form outlines a patient's rights to keep their medical records and insurance information private or accessible to other people as necessary. Use this question to highlight your understanding of these regulations and the importance of protecting patients' health information. Example: "When a patient calls regarding their account, I always verify their name, date of birth and account number, if they have it. If a family member or caregiver is calling on behalf of the patient, I ask for the patient's information along with the caller's name and relationship to the patient. This allows me to check that this person is listed on the patient's HIPAA form, and I can speak with the caller about the patient's account." If a patient calls the billing department upset about their account, how do you handle their concerns? Many medical billers are responsible for taking patient calls regarding billing and insurance, and patients can often be confused or upset when they receive a bill from their provider. This situational question tests your customer service and problem-solving skills, and you can answer this question using a hypothetical scenario or a real-life example from your experience. Use the STAR method for your answer to:
Example: "In my last role, I had a patient call about her daughter's recent visit to the doctor for strep throat. She was concerned about the amount we had billed her after filing a claim with her insurance, so I talked her through the bill over the phone. I first assured her that I could help her understand the amount she was charged. Then, I explained each procedure we billed her for—the visit and the test. I also went over her EOB to show her how much we charged for the copay when she came in, how much the insurance company was going to pay and how much the coinsurance was, which was her responsibility to pay. The woman said that she had been confused by the different amounts and was grateful for me helping her through it. I then took her payment over the phone so that we could settle her outstanding charges as soon as possible." Explain how your previous medical experience can help you in this role. Some people become medical billers after being in direct patient care roles, and this experience can be helpful in many ways. If you have this previous experience, use this question to highlight those skills and the ways you plan to apply them in a medical biller role. Consider listing an example of a situation in which your knowledge can be an advantage. Example: "As a former medical assistant, I'm familiar with the process of documenting diagnoses, tests and procedures, and I have a lot of experience working directly with patients. My knowledge of note taking can help me better understand the physician notes on patient records, allowing me to more accurately create claims. Also, my bedside manner translates to customer service, so I am comfortable talking to patients who may be confused or upset about their bills." How familiar are you with medical terminology?Patient charts and records often include doctor's notes on what kind of tests and care a patient received. Medical billers and coders often need to interpret these notes to accurately code these claims. In doing so, they must be familiar with some medical terminology, like certain conditions, procedures, tools and other jargon or abbreviations. In your answer, include an example of an instance where your knowledge of medical terms helped you on the job. Example: "When I was going to school for medical billing, I took a course on medical terminology so I could learn how to interpret notes on patient records, speak with the medical staff about patient accounts and help patients better understand their accounts. One time, a claim came back with an ERA that stated the diagnosis and procedure codes didn't coordinate. Since a diagnosis code has one or a few procedure codes that relate to it, I had to go back to the notes to double-check what the doctor diagnosed the patient with and what steps they took to care for them. I found that the coder may have made a clerical error while inputting the code, so I fixed the claim with the correlating code and resubmitted the claim." Do you have any medical billing or coding certifications?There are many forms of billing and coding certifications for this field, including Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient Coder (CIC) and Current Procedural Terminology (CPT). In your answer, identify whether you have any relevant certifications. If you don't have a certification, consider expressing interest in becoming certified to show your willingness to learn. Describe how do you prioritize different tasks throughout the dayA medical biller has many responsibilities and being able to manage your time and tasks each day can ensure your provider or healthcare group is paid on time and in full. Use this question to outline your day as a medical biller. Example: "Each morning, I start by returning voicemails and emails from patients. Then, I check any ERAs, denials or rejections from the clearinghouse. I work with my team to research the errors and fix claims in the EHR system. Then, I spend time going through the previous day's patients, making sure the physician's notes are signed and the claims are scrubbed. I then submit those claims through the clearinghouse. Throughout the entire day, I answer phone calls and answer questions from patients and providers about claims and accounts." Additional medical billing questions and answersWorking in medical billing can vary greatly from place to place while having a lot of detailed specifics in each, which makes for especially broad possibilities in interview questioning. Here are some additional questions you can practice:
Coding and billing for maternity obstetrical care is quite a bit different from other sections of the American Medical Association Current Procedural Terminology (CPT). Maternity care services typically include antepartum care, delivery services, as well as postpartum care. Depending on the patient’s circumstances and insurance carrier, the provider can either:
The Global Obstetrical PackageWhen discussing maternity obstetrical care medical billing, it is crucial to understand the Global Obstetrical Package. Most insurance carriers like Blue Cross Blue Shield, United Healthcare, and Aetna reimburses providers based on the global maternity codes for services provided during the maternity period for uncomplicated pregnancies. Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.) If the services rendered do not meet the requirements for a total obstetric package, the coder is instructed to use appropriate stand-alone codes. These might include antepartum care only, delivery only, postpartum care only, delivery and postpartum care, etc. When billing for the global obstetrical package code, all services must be provided by one obstetrician, one midwife, or the same physician group practice provides all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care. Here a “physician group practice” is defined as a clinic or obstetric clinic that is under the same tax ID number. It uses either an electronic health record (EHR) or one hard-copy patient record. Each physician, nurse practitioner, or nurse midwife seeing that patient has access to the same patient record and makes entries into the record as services occur. Individual Evaluation and Management (E&M) codes should not be billed to report maternity visits unless the patient presents for issues outside the global package. All prenatal care is considered part of the global reimbursement and is not reimbursed separately. The provider will receive one payment for the entire care based on the CPT code billed. Services Bundled with the Global Obstetrical PackageA key part of maternity obstetrical care medical billing is understanding what is and is not included in the Global Package. Services provided to patients as part of the Global Package fall in one of three categories. They are:
Antepartum CareAntepartum care comprises the initial prenatal history and examination, as well as subsequent prenatal history and physical examination. This includes:
Intrapartum Care AKA Labor & DeliveryLabor and delivery include:
Postpartum CarePostpartum care includes the following:
IMPORTANT: All of the above should be billed using one CPT code. Separate CPT codes should not be reimbursed as part of the global package. Services Excluded from the Global Obstetrical PackageCertain maternity obstetrical care procedures are either highly complex and/or not required by every patient. As such, including these procedures in the Global Package would not be appropriate for most patients and providers. The American College of Obstetricians and Gynecologists (ACOG) has developed a list of procedures that are excluded from the global package. If the provider performs any of the following procedures during the pregnancy, separate billing should be done as these procedures are not included in the Global Package.
Split Care Performed/Itemization BillingSome patients may come to your practice late in their pregnancy. Others may elope from your practice before receiving the full maternal care package. In such cases, your practice will have to split the services that were performed and bill them out as is. Examples of situations include:
If the patient had fewer than 13 encounters with the provider, your practice should contact the insurer to find out whether the insurer will honor the global package CPT code. Possible billings include:
Diagnosis Codes for Deliveries and Related Services
Who Is Eligible to Provide Patient Care?The following is a comprehensive list of eligible providers of patient care (with the exception of residents, who are not billable providers):
ModifiersDepending on your state and insurance carrier (Medicaid), there may be additional modifiers necessary to report depending on the weeks of gestation in which patient delivered. Before completing maternity obstetrical care billing and coding, always make sure that the latest OB guidelines are retrieved from the insurance carrier to avoid denials or short pays. In order to ensure proper maternity obstetrical care medical billing, it is critical to look at the entire nine months of work performed in order to properly assign codes. Pay special attention to the Global OB Package. The coder should have access to the entire medical record (initial visit, antepartum progress notes, hospital admission note, intrapartum notes, delivery report, and postpartum progress note) in order to review what should be coded outside the global package and what is bundled in the Global Package. The key is to remember to follow the CPT guidelines, correctly append diagnoses, and ensure physician documentation of the antepartum, delivery and postpartum care and amend modifier(s). One significant role of a midwife is providing mothers with quality of health services. It is our duty to provide them with proper care and comfort making sure that their pregnancy journey will be a memorable one. There are many more maternal billing and coding challenges that you may encounter much especially during this pandemic. You’ve got to figure out a way to provide prenatal checkups, physical exams, annual well checks, and vaccinations because both your patient’s health and your practice’s revenue are at stake.
Global maternity care includes pregnancy-related antepartum care, admission for labor and delivery care, management of labor including fetal monitoring, delivery, and uncomplicated postpartum care until six weeks postpartum. When billing for maternity care, it is crucial to understand the Global Obstetrical Package. Currently, global obstetrical care is defined by the AMA CPT as “the total obstetric package includes the provision of antepartum care, delivery, and postpartum care.” (Source: AMA CPT codebook 2022, page 440.) All services must be provided by a provider with all of the patient’s routine obstetric care, which includes the antepartum care, delivery, and postpartum care. Global Billing with CPT Code 59400-59618 Includes These Services The Global OB package covers patient care during the entire pregnancy — the antepartum period, delivery, and postpartum. Providers get paid a flat rate for the services rendered under these CPT global obstetric codes:
When billing with the global OB codes, front desk staff, coders and billers need to be aware of visits and services that aren’t part of routine maternity care. This allows schedulers to provide accurate information on possible patient costs and billers to charge separately. Proper global package code selection is essential to receive the maximum allowed reimbursement. There are times when one code might be paid but using the correct code will bring higher insurance payment. For example, if a patient has a cesarean delivery after an unsuccessful attempt at a vaginal delivery, code 59510 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, 67.00 relative value units) is in order. However, if this same scenario transpires after a prior cesarean delivery, 59618 (Routine obstetric care including antepartum care, cesarean delivery and postpartum care, following attempted vaginal delivery after previous cesarean delivery, 67.88 RVUs) is the proper code to use. CPT Code 59400 Includes Only Uncomplicated Services It’s important to note, global maternity billing covers services under normal, uncomplicated conditions. Global maternity billing does not cover:
Insurers Vary on CPT Code 59400 Billing, Payment Schedule, Duration Global billing for maternity care is beneficial to both patient and provider when the pregnancy follows an uncomplicated course. Some variables, however, can complicate matters for the provider’s revenue cycle. Considering the global maternity billing package spans a nine-month period, that’s a big window to wait for reimbursement. Variables to consider with insurance companies when billing for global maternity services are:
CPT Code 59400 Doesn’t Always Apply The CPT OB bundles are billed for and reimbursed when all services are rendered by a single providers or multiple providers from the same group. There are some situations that complicate global maternity billing and require the provider to bill the delivery, antepartum, and postpartum separately. These include when a:
Global Maternity Care Code Quick Reference Guide https://www.bcbsnd.com/content/dam/bcbsnd/documents/general/Global-Maternity-Quick-Reference-Guide.pdf References 1, P. O. (2022, April 1). CPT code 59400 Global Maternity Billing You Need To Know. Healthcare Training Leader. Retrieved May 30, 2022, from https://healthcare.trainingleader.com/2019/10/cpt-code-59400/ Billing is a function that is critical for the financial cycle of all health care providers including midwives. It requires attention to detail and experience with the electronic and paper systems used in billing healthcare services. It is clear that understanding billing procedure is important to you as a midwife. While you may see a lot of billing courses online and in some institutions, billing for your own practice is crucial and time consuming that may affect your practice as well.
Hiring a biller company could be an option that you can consider for your midwifery practice. If you will hire a biller company you can avoid doing everything on your practice like submitting timely medical claims to insurance companies and payers such as Medicare and Medicaid, preparing, reviewing, and transmitting claims using billing software, including electronic and paper claim processing, setting up patient payment plans and work collection accounts, updating billing software with rate changes, updating cash spreadsheets, and running collection reports and so many grueling tasks that will greatly affect your services. However, after you reached into the decision of hiring a biller company, the next consideration you should deliberate is asking “who will you hire?” Do you have any specific criteria based on your needs? Background checking with their previous clients, did they encounter previous issues and how they were able to overcome those issues. To help you with that, here are some questions that you can ask a biller company before hiring them for your midwifery practice. 1. What will it cost? This is always the main thing on everyone’s mind. The rate should be under 8% of collected charges. A percentage is a better option than a flat rate—the percentage usually goes down as your collections go up. Also ask about start-up fees, termination fees, data conversion fees, and any other additional costs. Some companies charge extra for patient collections follow up and other services. 2. Can they provide references? Have they worked with practices that are similar to yours in size, scope, and/or specialty? Do they have testimonials, or can you call someone directly for a reference? 3. Who owns your billing data? Your billing data should belong to you, and you should be able to take it with you if you choose to change services or bring your billing in-house. 4. What kind of training does the staff have? Are they certified? What type of ongoing training do they receive? Are they using the most up-to-date resources and guidebooks (i.e., CPT, HCPCS, etc.)? 5. Do they have any professional affiliations? Does the service, or its employees, maintain any professional affiliations such as HBMA? 6. Do they have a compliance plan in place? Are they HIPAA compliant? What are their security protocols? 7. Who will actually be working on your account? Can you meet (on the phone or in person) the actual people who will be working on your account? 8. Can you get a guarantee of transparency? How often will you receive reports showing the financial state of your business and the billing service’s progress? How will they communicate with you and how involved will you be in the billing processes? 9. Are most of their services electronic? In this day and age, most of the processes should be electronic from eligibility verification to remittances. They should also offer credit card processing and online bill pay for patients. 10. Are there billing follow up items that they don’t handle? Don’t assume that a billing service will do everything or that everything is included in your rate. Ask up front and be sure you know if there are services that they don’t offer. There are a lot of choices out there. You may have some questions that are specific to your needs, but the following ten questions should apply to any practice. Ask them to each service you speak with and then compare the answers. Use these questions to help guide your decision when selecting a medical billing service. It’s worth it to take your time evaluating your options so that you get the best service possible from the start. Additional Resources Lea Chatham Lea writes educational articles to help medical practices improve their businesses. In addition to Kareo. (2013, February 26). 10 questions to ask before hiring a medical billing service. Kareo. Retrieved May 13, 2022, from https://www.kareo.com/blog/article/10-questions-ask-hiring-medical-billing-service When we talk about matters pertaining to your client’s insurance, you have probably heard the terms “in-network” and “out-of-network” care thrown around quite a bit by different healthcare provider including midwives. But what do these terms actually mean, and more importantly what do they mean for you as a midwife? How will these affect your practice and you be able to apply these terms to your midwifery practice?
What does in-network mean? In-network refers to midwives that have direct contract with the health insurance plan to provide health care services to its plan members at a pre-negotiated rate. Because of this relationship, clients pay a lower cost-sharing when they receive services from an in-network midwife. What does out-of-network mean? Out-of-network refers to midwives who does not have a contract with the health insurance plan. If a client uses an out-of-network provider, health care services could cost more since midwives don’t have a pre-negotiated rate with the client’s health plan. Or, depending on the health plan, the health care services may not be covered at all. Depending on the coverage the client has purchased, the plan has established deals with a wide range of midwives and other specialists. These are the health care providers that the insurance company considers in your client’s “network.” The insurer has identified a group of providers who are “in-network” and has contracted with these providers on the client’s behalf to get services at “discounted” rates. The primary advantage of using an in-network provider is that your client receives this negotiated or discounted rate for your services, and the insurance provider generally picks up a larger portion of the bill than with an out-of-network provider. This means that as a midwife, once you’re in an agreement with the insurance company to accept your client’s plans and contracted rate as payment for your full services. This contracted rate that was negotiated by your client and its insurance company includes both the insurer’s share of the cost, and the part that your client will be responsible for paying. The part that your client’s responsibility for paying may be in the form of a co-payment, co-insurance or deductible depending on their negotiation. Simply speaking, as a midwife, when you accept your client’s health insurance plan we say you’re in network. You will also be called as “participating providers.” When you don’t take your client’s plan, we say you’re out of network. The two main differences between them are cost and whether the plan helps you receive enough value for the care you provide as out-of-network provider. Healthcare is an important aspect of our daily lives. As a healthcare provider, we are expected to give the best services to our clients and in order for our practice to keep on growing we must receive proper compensation out of that service. Remind your clients that they can avoid unexpected medical bills by knowing how their plan works. Certain choices they make can affect what they'll pay out-of-pocket. Know the difference between in-network and out-of-network care to help them save on health care expenses. Resources: Outreach & Education. CMS.gov Centers for Medicare & Medicaid Services Health Insurance. (n.d.). Retrieved May 13, 2022, from https://marketplace.cms.gov/outreach-and-education https://www.desertridgeperiodontics.com/pdf/In%20Network%20vs%20Out%20of%20Network.pdf |
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