Question

.Dr. Smith recently started his own practice and has a high population of Medicare patients. His staff has not received formal training or education in billing practices, which has resulted in 85% of his claims being denied. Dr. Smith has privileges at Mercy General and performs a large amount of their inpatient and outpatient surgeries. Additionally, patients have begun to complain because their admission or procedure is denied or delayed because pre-authorization was not obtained or they received a letter from their insurance company denying part of or the entire bill because the procedure could have been done on an outpatient basis. Dr. Smith has hired a new office manager who is a health information management professional with billing and coding experience.

#1 Describe the system used to reimburse the physician services Dr. Smith gives to his Medicare patient.

Answer 1

The physician who offer their service to Medicare patient are paid less when compared with the private insurance company.The reason behind it being the more care needed by the patients.The physician are classified and paid on three basis namely participating orovider,non participating provider and opt out provider.

The CPR (Customary, Prevailing and reasonable charge) is the method used for reimbursements by the physician

The CMS 1500 Medical claim form has to be filled and sent online.(This is done by correct filling in the fields,clear insurance information, use correct COT codes and diagnosis code,mention correct service location facility of the physician, and mention NPI information

The reimbursement for a physician occurs in three steps

• The exact or appropriate coding to be done for the services offered using current CPT
• The proper coding of diagnosis using ICD 9
• The center for Medicare and Medicaid services determines the fee based on Resource based relative value scale.

The newly hired HIM personnel has to do this work more efficiently to avoid errors and preventing any denial or delay from the Medicare.