MEDICAL INSURANCE

AND BILLING SERVICES

OF BRIGADICAL
MEDITECH PVT.LTD
AND PETIENT
SATICSFATION OF
MAYO HOSPITAL
 TABLE OF CONTENT

1 Introduction of the topic

(A) KPO and BPO industry in India

(B) Medical billing and insurance with the

help of KPO and BP

2 Profile of the Company

(A) Profile of bridicalmeditech

3 Research Methodology

(A) Title of the Study

(B) Duration of the Project

(C) Objective of Study

(D) Type of Research

(E) Limitation of Study

4 Analysis and Presentations

5 Findings

(A) Conclusion and

(B) Recommendations suggestion

6 Appendices

(A) Bibliography

(B) Questionnaire
 CHAPTER-1
INTRODUCTION
OF
THE PROJECT
1.1 KPO and BPO industry in India:

THE BPO INDUSTRY IN INDIA

In India, Business Process Outsourcing (BPO) is the fastest growing segment of the ITES
(Information Technology Enabled Services) industry. Factors such as economy of scale,
business risk mitigation, cost advantage, utilization improvement and superior
competency have all lead to the growth of the Indian BPO industry. Business process
outsourcing in India, which started around the mid-90s, has now grown by leaps and
bounds.

India is now the world's favored market for BPO companies, among other competitors,
such as, Australia, China, Philippines and Ireland. The BPO boom in India is credited to
cheap labor costs and India's huge talent pool of skilled, English-speaking professionals.
Research by the National Association of Software Services and Companies (NASSCOM)
has revealed that quality orientation among leading BPO companies, 24/7 services,
India's unique geographic location and the investor friendly tax structure in India have all
made the BPO industry in India very popular

The term Business Process Outsourcing or BPO as it is popularly known, refers to

outsourcing in all fields. A BPO service provider usually administers and manages a
particular business process for another company. BPOs either use new technology or
apply an existing technology in a new way to improve a particular business process. India
is currently the number one destination for business process outsourcing, as most
companies in the US and UK outsource IT-related business processes to Indian service
providers.

Services offered by Indian BPO companies

Indian BPO companies offer varied services, such as, customer support, technical
support, telemarketing, insurance processing, data processing, forms
processing, bookkeeping and internet / online / web research.

1. Customer support services:

24/7 inbound / outbound call center services that address customer queries and
concerns through phone, email and live chat.

2. Technical support services:

Installation, product support, running support, troubleshooting, usage support and

problem resolution for computer software, hardware, peripherals and internet
infrastructure.

3. Telemarketing services:

Interacting with potential customers and creating interest for the customer's services/
products. Up-selling, promoting and cross selling to existing customers and
completing online sales processes.

4. IT help desk services:

Level 1 and 2 multi-channel support, system problem resolutions, technical problem

resolution, office productivity tools support, answering product usage queries and
performing remote diagnostics.

5. Insurance processing:

New business acquisition and promotion, claims processing, policy maintenance and
policy management.
 6. Data entry and data processing:

Data entry from paper, books, images, e-books, yellow pages, web sites, business
cards, printed documents, software applications, receipts, bills, catalogs and mailing
lists.

7. Data conversion services:

Data conversion for databases, word processors, spreadsheets and software

applications. Data conversion of raw data into PDF, HTML, Word or Acrobat
formats.

8. Bookkeeping and accounting services:

Maintenance of the customer's general ledger, accounts receivables, accounts

payables, financial statements, bank reconciliations and assets / equipment ledgers.

9. Form processing services:

Online form processing, payroll processing, medical billing, insurance claim forms
processing and medical forms processing.

10. Online research:

Internet search, product research, market research, surveys, analysis, web research
and mailing list research.

Interesting facts about the Indian BPO industry

 The BPO sector in India is estimated to have reached a 54 per cent growth in revenue
 The demand for Indian BPO services has been growing at an annual growth rate of
50%
 The BPO industry in India has provided jobs for over 74,400 Indians. This number is
continuing to grow on a yearly basis. The Indian BPO sector is soon to employ over
1.1 million Indians
 70% of India's BPO industry's revenue is from contact centers, 20% from data entry
work and the remaining 10% from information technology related work
 Indian BPOs handle 56% of the world's business process outsourcing
Advantages of the BPO Industry
The purpose for organizations to outsource their commercial enterprise tactics is pretty
easy. Business Process Outsourcing allows commercial enterprise proprietors to lessen
the weight of work and concentrate on other center aspects in their operation.
Outsourcing to a third-birthday celebration organization, that’s already properly-set up
and has the applicable experience in supplying services, is a miles greater convenient
option. Outsourcing your enterprise strategies comes with a sequence of advantages.
Some of these include:

1. Cost Reduction:

Outsourcing helps agencies reduce expenses and save money, and is one of the
maximum critical motives for people opting to outsource their commercial enterprise
system. BPO has given upward push to a talented pool of employees to be had at low
wages results in massive value reductions, which in flip outcomes in better sales for the
organization

2. Availability of Experienced Professionals:

Recruiting new employees and schooling them includes quite a few problem and is a big
cost to the enterprise. When the responsibilities are outsourced to an already hooked up
enterprise with all the resources, the problems of hiring and education is without
problems prevented

3. Ability to Focus on Core Business: Since a large chew of the business is outsourced
to a service issuer, the pinnacle management of the employer can recognition their
attention on core operational areas. This also ends in better employee productivity and
allows them make better and greater informed business decisions

4. Excellent Source of Customer Feedback:

Most BPO employees are in direct contact with the customers, as a result of which they
may be able to acquire a primary-hand comments approximately services and products.
This valuable comments, in flip, enables the employer to improve upon the offerings
provided

5. Access to the Latest Updated Technologies:

Buying an authorized version of the latest software and other technologies may be very
costly. This proposition is also risky, in particular for small to medium-sized groups who
can’t come up with the money for to commit a regular price range to shopping for the
today’s technologies. Therefore, it will become difficult for a organization to live updated
with the modern-day trends. Outsourcing to groups that already have get entry to to the
generation and feature the applicable understanding therefore proves to be extra
wonderful for international organizations

6. Excellent Employment Opportunity:

The BPO enterprise is one of the highest activity vendors in most nations. In truth, it’s
miles the ranked 2nd in phrases of the quantity of jobs created in some of the Asian
international locations. The remuneration furnished to the personnel is also one of the
first-rate inside the industry, which is one of the main motives for kids to works in BPO.
The BPO industry has provided employment to loads of proficient kids and has
unmarried-handedly modified the GDP of diverse small international locations

The top fifteen BPO companies in India

NASSCOM recently conducted a survey and evaluated the leading BPO service
providers across India. The top fifteen business process outsourcing companies in India
are:
 WNS Group
 Wipro Spectramind
 Daksh e-Services
  Convergys
 HCL Technologies
 Zenta
 First Source
 MphasiS
 EXL
 Tracmail
 GTL Ltd
 vCustomer
 HTMT
 24/7 Customer
 Sutherland Technologies

KNOWLEDGE PROCESS OUT SOURCING

India, with its large pool of talented professionals and specialized domain workers, is
quickly becoming the central hub for what is known as Knowledge Process Outsourcing
(KPO).

The Indian KPO sector offers global customers with a wide range of services among
various industry verticals. Apart from IT/ ITES related services, the KPO industry
provides several knowledge-based solutions such as Engineering Services, Web
Application Development, CAD/ CAM Applications, Legal Processes, Intellectual
Property and Patent Services, Business Research and Analytics, Legal Research, Clinical
Research, Publishing and Market Research amongst others.

Popular KPO Services Offered in India

With the current highly competitive market scenario, many global companies and
organizations are making the choice of focusing on their core business areas and
outsourcing all of their other non-core business activities. This gives them the advantage
of minimizing their costs, improving efficiencies and shifting the focus onto the key
growth areas of their business. Outsourcing knowledge-based services to India offers
companies with greater benefits, as they can get access to domain-based processes and
advanced analytical skills, rather than just process expertise.

Today, the Indian KPO sector offers organizations the choice of a multitude of
knowledge-based services across industry verticals. Indian outsourcing companies, such
as, Outsource2india are experts in:

 Market Research

 Financial Research Services

 Learning Solutions

 Business Research

 Pharmaceuticals and Biotechnology

 Medical Services

 Writing and Content Development

 Legal Process Outsourcing

 Intellectual Property (IP) Research

 Data Analytics

 Creative Design

 Network Management

 Training and Consultancy

Advantages of Knowledge Process Outsourcing to India:

Top ten KPO Companies in India:

• Genpect

• Evalueserve

• Ugam Solutions

• WNS Global Services

• 24/7 Customer

• ICICI OneSource

• EXL Service

• Copal Partners

• Pangea3

• TechBooks

1.2 Medical billing and insurance with the help of KPO and
BPO:
1.2.1 Introduction - Medical Billing:

Overview of Insurance Scenario:

Gone are the days when the physician used to accept entire amount due from all the
patients directly and immediately after the services was rendered. In those days medical
expenses was affordable. But it is a different scenario now. Costs of medical expenses are
so high that a normal middle class people will not be able to afford the entire cost of
medical expense. Here is where the insurance company comes into picture.

When patient takes policies with a health insurance company, the insurance takes the
responsibility of all the financial risks undergone by the patient in relation to medical
treatment for himself or is dependent’s during the tenure of the policy. Since insurance
companies carry financial risks they are also referred as carriers. The terms and
conditions of a patient ‘s medical policy clearly define its scope. The scope may be
limited to a given set of benefits or subject to certain conditions. Only if the services are
within the scope of the policy and only if the conditions, if any, are met will the services
will be covered and reimbursed by the carrier.

In recent times insurance sector has come along way in health care reimbursement.

Concept of Medical Billing

The physician does not get paid for his services immediately after they are rendered.
Majority of the patients has insurance coverage and details of such coverage are provided
to the physician before treatment. It is the responsibility of the physician to submit claims
to the insurance company and get paid for his services. Submitting claims and getting
paid is not as simple as it looks. It is a lengthy process and involves a lot of rules and
regulations, systems and is very complicated. The physician cannot provide his entire
attention to this activity. Hence the concept of Medical Billing arose.

Parties in Medical Billing

There are three parties in Medical Billing Process. The PHYSICIAN, The INSURANCE
COMPANY and The PATIENT. The Physician in order to attain his objective both
should comply with the rules and regulations spelt out by various insurance companies in
submitting claims and at the same time doe not penalize the patient.

Role of Medical Billing Companies

Physicians appoint Medical Billing Companies to take care of their billing. The Medical
Billing Companies should clearly spell out their duties and responsibilities in their
agreement with the physician. The agreement should also clearly state the process to be
adopted by the Billing Office in carrying out the objectives. If there are any assumptions
to be made it should be clearly stated and in case of problematic issues the course of
action should be well defined and the responsibilities should be mentioned. The main
objective of the Billing Company is to maximize the collections.

Functions of a Medical Billing Company

In simple term, the main function of a Medical Billing company is to help healthcare
providers and organizations process patient/client information in order to get paid on
time. The term "healthcare providers" means Physicians, Psychotherapists, Psychiatrists,
Chiropractors, Nursing Practitioners, Dentist, Medical Social Workers, Physical
Therapists, Occupational or Speech Therapists. It also include healthcare businesses such
as: Ambulatory Services, Durable Medical Equipment Suppliers, Medical and Surgical
Suppliers, Medical Laboratories and Clinics. And organizations such as Nursing Homes,
Home Health Care Agencies, Rehabilitation Centers, Hospice Care Centers, and
Hospitals. Claims filing to private insurance companies and government sponsored
programs such as Medicare and Medicaid consist of the main business of a Medical
Billing Service Company. However, we cannot ignore the importance of good record
keeping - medical and otherwise to justify why we bill for whatever condition. Also, part
of Medical Billing Company’s job is to make sure clients maintain compliance with
whatever government rules and regulations there are.

Trained professional billing centers process and transmit completed claims, via computer
modem, to a central clearinghouse. Claims are audited and forwarded for payment to
thousands of commercial, private and government healthcare plans.

While paper claims can take months to process, electronic claims are processed in just 14
days. This means a medical billing service, which provides the electronic claims
handling, can ultimately offer a health care practice a better and more consistent cash
flow, which can reduce stress and frustration and improve profitability.

Before being able to understanding how to bill and file an insurance claim, you must
understand what health insurance is? It is imperative that the medical biller understands
the various types of insurance and that each insurance company has its own rules’,
regulations, and policy guidelines they are governed by. A medical biller will need to
understand the physician’s responsibilities and obligations to the patients, as well as any
agreements the physician has with the insurance companies regarding, adjustments,
charges and coding basics. Without this basic knowledge, a medical biller will find it
difficult to combat the common problems of claims submission.
Medical Billing process:

The medical billing process is a process that involves a health care provider and the
insurance company (payer) pertaining to the payment of medical services rendered to the
clients. The entire procedure involved in this is known as the billing cycle sometimes
referred to as Revenue Cycle Management. Revenue Cycle Management involves
managing claims, payment and billing. This can take anywhere from several days to
several months to complete, and require several interactions before a resolution is
reached. The relationship between a health care provider and insurance company is that
of a vendor to a subcontractor. Health care providers are contracted with insurance
companies to provide health care services. The interaction begins with the office visit:
a physician or their staff will typically create or update the patient's medical record.

After the doctor sees the patient, the diagnosis and procedure codes are assigned. These
codes assist the insurance company in determining coverage and medical necessity of the
services. Once the procedure and diagnosis codes are determined, the medical biller will
transmit the claim to the insurance company (payer). This is usually done electronically
by formatting the claim as an ANSI 837 file and using Electronic Data Interchange to
submit the claim file to the payer directly or via a clearinghouse. Historically, claims
were submitted using a paper form; in the case of professional (non-hospital)
services Centers for Medicare and Medicaid Services. At time of writing, about 30% of
medical claims get sent to payers using paper forms which are either manually entered or
entered using automated recognition or OCR software.

The insurance company (payer) processes the claims usually by medical claims
examiners or medical claims adjusters. For higher dollar amount claims, the insurance
company has medical directors review the claims and evaluate their validity for payment
using rubrics (procedure) for patient eligibility, provider credentials, and medical
necessity. Approved claims are reimbursed for a certain percentage of the billed services.
These rates are pre-negotiated between the health care provider and the insurance
company. Failed claims are denied or rejected and notice is sent to provider. Most
commonly, denied or rejected claims are returned to providers in the form of Explanation
of Benefits (EOB) or Electronic Remittance Advice.

In case of the denial of the claim, the provider reconciles the claim with the original one,
makes necessary rectifications and resubmits the claim. This exchange of claims and
denials may be repeated multiple times until a claim is paid in full, or the provider relents
and accepts an incomplete reimbursement.

There is a difference between a “denied” and a “rejected” claim, although the terms are
commonly interchanged. A denied claim refers to a claim that has been processed and the
insurer has found it to be not payable. A denied claim can usually be corrected and/or
appealed for reconsideration. Insurers have to tell you why they’ve denied your claim and
they have to let you know how you can dispute their decisions. A rejected claim refers to
a claim that has not been processed by the insurer due to a fatal error in the information
provided. Common causes for a claim to reject include when personal information is
inaccurate (i.e.: name and identification number do not match) or errors in information
provided (i.e.: truncated procedure code, invalid diagnosis codes, etc.) A rejected claim
has not been processed so it cannot be appealed. Instead, rejected claims need to be
researched, corrected and resubmitted.

Electronic billing

A practice that has interactions with the patient must now under HIPAA send most billing
claims for services via electronic means. Prior to actually performing service and billing a
patient, the care provider may use software to check the eligibility of the patient for the
intended services with the patient's insurance company. This process uses the same
standards and technologies as an electronic claims transmission with small changes to the
transmission format, this format is known specifically as X12-270 Health Care Eligibility
& Benefit Inquiry transaction. A response to an eligibility request is returned by the payer
through a direct electronic connection or more commonly their website. This is called an
X12-271 "Health Care Eligibility & Benefit Response" transaction. Most practice
management/EM software will automate this transmission, hiding the process from the
user.

This first transaction for a claim for services is known technically as X12-837 or ANSI-
837. This contains a large amount of data regarding the provider interaction as well as
reference information about the practice and the patient. Following that submission, the
payer will respond with an X12-997, simply acknowledging that the claim's submission
was received and that it was accepted for further processing. When the claim(s) are
actually adjudicated by the payer, the payer will ultimately respond with a X12-835
transaction, which shows the line-items of the claim that will be paid or denied; if paid,
the amount; and if denied, the reason.

Payment

In order to be clear on the payment of a medical billing claim, the health care provider or
medical biller must have complete knowledge of different insurance plans that insurance
companies are offering, and the laws and regulations that preside over them. Large
insurance companies can have up to 15 different plans contracted with one provider.
When providers agree to accept an insurance company’s plan, the contractual agreement
includes many details including fee schedules which dictate what the insurance company
will pay the provider for covered procedures and other rules such as timely filing
guidelines.

Providers typically charge more for services than what has been negotiated by the
physician and the insurance company, so the expected payment from the insurance
company for services is reduced. The amount that is paid by the insurance is known as
an allowable amount.

For example, although a psychiatrist may charge $80.00 for a medication management
session, the insurance may only allow $50.00, and so a $30.00 reduction (known as a
"provider write off" or "contractual adjustment") would be assessed. After payment has
been made, a provider will typically receive an Explanation of Benefits (EOB) or
Electronic Remittance Advice (ERA) along with the payment from the insurance
company that outlines these transactions.

The insurance payment is further reduced if the patient has a copy, deductible, or
a coinsurance. If the patient in the previous example had a $5.00 copay, the physician
would be paid $45.00 by the insurance company. The physician is then responsible for
collecting the out-of-pocket expense from the patient. If the patient had a $500.00
deductible, the contracted amount of $50.00 would not be paid by the insurance
company. Instead, this amount would be the patient's responsibility to pay, and
subsequent charges would also be the patient's responsibility, until his expenses totaled
$500.00. At that point, the deductible is met, and the insurance would issue payment for
future services.

A coinsurance is a percentage of the allowed amount that the patient must pay. It is most
often applied to surgical and/or diagnostic procedures. Using the above example, a
coinsurance of 20% would have the patient owing $10.00 and the insurance company
owing $40.00.

Steps have been taken in recent years to make the billing process clearer for patients. The
Healthcare Financial Management Association (HFMA) unveiled a "Patient-Friendly
Billing" project to help healthcare providers create more informative and simpler bills for
patients. Additionally, as the Consumer-Driven Health movement gains momentum,
payers and providers are exploring new ways to integrate patients into the billing process
in a clearer, more straightforward manner.

Medical billing services

Info graphic showing how healthcare data flows within the billing process

In many cases, particularly as a practice grows, providers outsource their medical billing
to a third party known as medical billing companies who provide medical billing
services. One goal of these entities is to reduce the amount of paperwork for a medical
staff and to increase efficiency, providing the practice with the ability to grow. The
billing services that can be outsourced include: regular invoicing, insurance verification,
collections assistance, referral coordination and reimbursement tracking. Healthcare
billing outsourcing has gained popularity because it has shown a potential to reduce costs
and to allow physicians to address all of the challenges they face daily without having to
deal with the daily administrative tasks that consume time.

Medical billing regulations are complex and often change. Keeping your staff up to date
with the latest billing rules can be difficult and time-consuming, which often leads to
errors. Another main objective for a medical billing service is to use its expertise and
coding knowledge to maximize insurance payments. It is the responsibility of the medical
billing service you choose to ensure that the billing process is completed in a way that
will maximize payments and reduce denials Payment posting important part of the
medical billing.

Practices have achieved significant cost savings through Group purchasing

organizations (GPO), improving their bottom line by 5% to 10%. In addition, many
companies are looking to offer EMR, EHR and RCM to help increase customer
satisfaction; however as an industry the CSAT levels are still extremely low

1.2.2HEALTH INSURANCE
The dictionary defines Insurance as: “Protection against risk, loss or ruin by a contract in
which an insurer (the insurance company) guarantees to pay a sum of money to the
insured (you) in the event of some contingency (a random occurrence) such as an
accident, a death, or illness, in return for the payment of a premium”. Among the many
types of insurance are health, disability, liability, malpractice, property, auto and life
insurance.

Health Care Insurance is a contract between a policyholder* and an insurance carrier (or
government program) to reimburse the policyholder for all or a portion of the cost of
medically necessary treatment rendered by health care professionals. In some policies the
contract can include preventive care as well as medically necessary treatment.

(*A policyholder is an individual in most cases. In Group health insurance the

policyholder will be the employer the individual works for who holds the contracted with
the insurance company. )

Medical biller need to recognize the various ways in which a patient may obtain health
insurance coverage. There are three way a person may obtain health insurance coverage:
1. Group Health Plan: a plan arranged by an employer or special interest group for the
benefit of members and their eligible dependents. This plan provides maximum benefit
packages based on desired coverage and cost factors. Group policies are often benefits of
employment that are provided by the employer with little or no cost to the insured
(employee).

2. Individual or : a plan issued to an individual. This type of coverage has a high

premium with benefits based on the needs and financial factors of the individual
policyholder.

3. Government programs are designed to provide benefits and health care for individuals
who would not otherwise be able to afford them. These programs are Medicare,
Medicaid, and CHAMPUS programs.

Health insurance was designed to assist the patient with the expenses incurred for
medical treatment. The insurance company did not design their policies to alleviate the
patient of the financial burden of medical care.

The carrier cannot be expected to provide reimbursement for which coverage has not
been purchased. This refers to a benefit that is not in the contract, such as an individual
who purchases a policy with only hospital coverage, the carrier cannot be expected to
reimburse the physician’s charges.

THE INSURANCE CARRIER

The insurance company, which writes and administers the policy, is commonly referred
to as the CARRIER. It is also known as the insurer, underwriter or administrative agent.
Carriers are responsible for providing coverage as outlined in the contract between the
company and the insured (an individual person) or contracting group (an employer group
or corporate group).

A few examples are Blue Cross/Blue Shield, Aetna Health Plans, Cigna Health Plans,
Health Choice, etc. Currently there are over 2000 health insurance carriers in the United
States. There is a book that can be purchased, Health Insurance Carrier Directory, by
PMIC. This book is updated every year, it lists each company address and phone numbers
and it can be purchased at most bookstores.

Each insurance carrier offers many different types of plans and will at times customize a
plan for a large corporation. It is also known that the major insurance companies (except
for Medicaid programs, which are managed, by data processing companies) administer
most government health care programs. Thus a single carrier may sell individual policies
and group plans, and administers a government program such as Medicare.

TYPES OF HEALTH INSURANCE COVERAGE

The major types of health insurance coverage fall neatly into seven categories:
Commercial, Blue Cross and Blue Shield, Medicare, CHAMPUS, Medicaid, Worker’s
Compensation and Health Maintenance Organizations (HMOs).

This is not to say that the following seven health insurance types are the only types of
insurance coverage.

COMMERCIAL CARRIER

Commercial carriers offer contracts to individuals and groups, mostly groups, under
which payments are made to the beneficiary (or to the providers if they have accepted
assignment of benefits) according to an indemnity table or schedule of benefits for
medical services. Commercial plans generally do not have special contract agreements
with physicians. In commercial plans it up to the patient to file their claims. It should be
noted that not every service is covered under commercial plans; each one has it own
benefits and exclusions. In general, most commercial plans use UCR as a basic for
maximum payment cost. Most commercial plans conform to one of three basic types:

Basic Medical Plans

These pay total costs up to a maximum (usually around $5000) for all but a few
exclusions such as cosmetic surgery and mental disorders. There are no deductibles or co-
payments and all benefits are usually a small amount of the actual fee but the benefit
amount that is paid is a 100%. These benefits include hospital, office, physician and lab
charges. These types of plans cover minor health problems.

Major Medical Plans

These policies are designed for catastrophic situations only, and there is no payment
under such plans for minor health problems. They usually take up where basic plans
leave off, and almost always have large deductibles and copayments.

Comprehensive Medical Plans

These plans consist of combinations of Basic and Major Medical benefits. It combines
the best of both plans, giving the insured a small benefit payable at 100% for the minor
illness’ that occur with the balance of all charges being applied to the major medical
portion of the plan, where its subject to the deductible and a coinsurance.

THE BLUE’S

Blue Cross

Blue Cross pertains to inpatient hospital services, nursing homes, and home health care
services to their subscribers. Independent, generally non-profit community service
organizations that provide prepaid health care services to their subscribers. They are
called “prepayment” plans because individuals pay in advance for the health services they
may need. In many states the Blues’ (Blue Cross and Blue Shield) have merged, to
provide comprehensive coverage for hospital and non-hospital services. Some Blue Cross
plans have over time converted to “for profit”.

Blue Shield

Blue Shield is the portion of a patient’s insurance providing financial assistance with
outpatient costs for services, physician charges, etc. There are many different programs
within the system. A review of a few of the programs most common to the medical
biller’s area will help the medical biller become more familiar with the groups with
whom the local providers may participate. Blue Shield has provisions for two types of
providers:

1. Indemnity providers – this provider has a contract to see Blue Shield patients, the
physician is not obligated to file insurance claims or write off the difference of the actual
charge and the allowed charge. The providers office may collect in full from the patient at
the time service is rendered.
2. UCR providers – this provider has a special contract with Blue Shield whereby the
physician agrees to see Blue Shield patients, file insurance claims and wait for the
payment before collecting from the patient. The physician also agrees to write off the
difference between the actual charge and the Blue Shield allowed charge.

Blue Cross and Blue Shield also administer Medicare, Medicaid, and CHAMPUS
programs in many states.

MEDICARE

Medicare is a health insurance program under the Social Security Administration’s

Health Care Financing Administration (HCFA) and it consist of two parts.

Medicare part ‘A’

This is hospital insurance (including skilled nursing facilities and home health care) for
almost everyone over the age of 65, the permanently disabled, and those with chronic
renal disease. Coverage under Part ‘A’ Medicare is automatic. The fiscal intermediary
for Part ‘A’ Medicare is the National Blue Cross Association, who in turn subcontracts
payment responsibilities to its member agencies.

Medicare part ‘B’

This is known as Supplementary Insurance. It covers physicians’ services, laboratory test

and x-rays. It is an elective service, the recipient must pay a monthly premium for Part
‘B’ coverage. Therefore not all Medicare recipients may not have Part ‘B’ coverage. The
Medicare ID card determines the exact coverage of the patient. If a date of eligibility is
not listed on the member’s card for Part ‘B’, then the patient is not eligible for Part ‘B’
coverage. Medicare Part ‘B’ program is administered by private insurance carriers who
place bids with the government to become fiscal intermediaries. A few districts are under
the direction of large, commercial carriers, most of Part ‘B’ program is administered by
Blue Shield. There is an annual deductible and a 20% co-payment.

Medi-Medi (Medicare-Medicaid cross-over)

A cross-over patient is one who has Medicare as primary coverage and Medicaid as
secondary coverage due to low income status.

Medicaid

This is health care assistance program administered jointly by the federal and state
governments. Each state sets up and operates its own program within the general
guidelines set down by the federal government. This is not an insurance program. It is a
state funded assistance program. Eligibility is month-to-month and based on the income
of the recipient.

The claim forms used must be those designated by the carrier. They must be submitted
within certain dates, complete in every detail, and routed first to all other possible sources
of payment.

CHAMPUS

Civilian Health and Medical Program of the Uniformed Services. This program that
makes health care benefits available to dependents of active military personnel, as well as
retired military personnel and their families. These people can go non-military doctors for
medical services and have part of the cost paid by the Federal government. At age 65, all
CHAMPUS beneficiaries are transferred to the Medicare program. CHAMPUS is similar
to Medicare, but there are differences in the deductible and co-payments.

WORKER’S COMPENSATION

This covers medical expenses and disability benefits for workers whose injuries or
illnesses are the result of doing their jobs. All employers with over a specific number of
employees is required to carry Workers Compensation insurance with a carrier of the
employer’s choice. Worker’s Compensation insurance and its billing are highly
specialized and it is not covered in this textbook.

HEALTH MAINTENANCE ORGANIZATIONS

The previous six lists deal with organizations which pay for medical services but do not
provide it. Health Maintenance Organizations (HMO) are prepaid group practice plans
where the patient or patient’s employer pays monthly premiums. When services are
rendered to the patient the patient does not pay any additional payments, co-payment or
deductibles.

There are four types of HMO’s:

Prepaid group Practice Model

This type of HMO delivers medical services at one or more locations through a group of
physicians who contract with the HMO to provide care or thorough its own physicians,
who are employees of the HMO. Kaiser-Permanente is the most well-known HMO of this
type.

Staff Model

This type hires physicians directly and pays them a salary instead of contracting with a
medical group.

Independent Practice Association (IPA)

In this type of plan the physicians are not employees and are not paid salaries. They are
paid fees for their services out of a fund drawn from the premiums collected by the
organization that markets the health plan. An IPA makes contractual arrangements with
physicians in the community who provide services from their own offices.

Network HMO

In this type of plan the HMO contracts with two or more group practices to provide
health care services to its members.

TYPES OF INSURANCE PLANS

Each insurance carrier offers many different types of plans, many carriers will customize
a plan for a large groups and/or corporation. There are many forms of health insurance
plans currently in effect in the United States. Some examples of these are, Blue Shield
who has hundreds of plans throughout the U.S., or Alliance and Alliance Plus, who is
part of a PPO network that Blue Shield pays 90% of the allowed charge and the patient
paying a 10% co-payment. Blue Choice is an HMO program incorporated by Blue Shield
in 1988. Plus Blue Shield has numerous comprehensive commercial programs known as
fee-for-service programs. There are Central Certification Programs that cover major
corporations with employees all across America. This program allows these employees to
receive benefits of the contract regardless of the state where the service is performed.

Each and every insurance carrier has their own versions of IPA’s, PPO’s, HMO’s,
Comprehensive plans, major medical and basic plans.

What does this mean to you as a medical biller? As a medical biller you should be aware
that not all insured’s under Blue Cross or Blue Shield has the exact same coverage. Each
of these policies will have different rules and regulations it is governed by, with different
Exclusions and Limitations. This goes for any insurance carrier, each having hundreds of
plans all with different individual Exclusions and Limitations.

A medical biller in a provider’s office, request a copy of the patient’s policy handbook.
This handbook is always given by the insurance carrier or the patient’s employer (if a
Group Plan). Photocopy the policy provisions and benefits, write down phone numbers of
where benefits are to be verified and if pre-authorizations are required being an
independent biller for several providers, knowing the patient’s exact benefits is not a
major necessity, the pre-authorizations, benefits, deductibles and request for additional
information are the responsibility of the provider’s office staff, since they are the ones
receiving the payments and EOB’s directly.

THE CONTRACT

The contract (or policy) is the document that describes the plan benefits, eligibility,
effective date, termination of coverage and Exclusions.

Basic health insurance coverage includes benefits for hospital, surgical and other medical
expenses. These contracts or policies are designed to offset large medical expenses
caused by prolonged illness or serious injury.
the applicant becomes part of the insurance contract or plan. An insurance policy is a
legal document between the insured, which can be an individual person or an employer
group. Each party must abide by the terms set forth in the contract. The insured receives a
formal written policy from the insurance carrier in legal language that needs an attorney
to interpret. Whereas, most insurance carriers also give the insured a coverage booklet,
this is especially true in the case of an employer group. The booklet is a simplified
explanation or interpretation of the actual policy or contract. The booklet gives general
information of the contract or policy.

THE PLAN

The contract is also known by other terms such as ‘plan’ or ‘policy’. The insurance
carriers structure the contract or plan to ‘spell-out’ the benefits available to the insured
and his dependents. The insurance carrier uses this contract or plan as a guideline to
determine a patient’s benefits and payments. Not every minute detail or service can be
predicted or written into a plan, if it were, the document would read like a never-ending
soap opera!

The contract or plan does give exact amounts in terms of the deductibles, coinsurance,
and maximums. But where it comes to specialized procedures and services, questionable
types of providers, and individual insurance carrier rules and regulations, these areas are
not always “so exact” and sometimes not even mentioned in the plan.

When verifying patients’ insurance benefits the insurance carrier is very important. In
Appendix II you will find several types of Insurance Benefits forms. These forms are
used by the doctors’ office to verify the patients’ insurance benefits. Asking question
such as plan deductibles, maximums, percentages, and second surgical opinions.

PLAN PROVISIONS

Health insurance plan provisions cover items as renewals, coordination of benefits with
other carriers, assignments, plan limitations, case management, and exclusions.

few of the key terms of insurance industry.

Assignment of Benefits: this term means the insurance carrier will send the payment
directly to the provider. To determine where and who the payment will be sent the
insurance carrier refers to Block 13 on the HCFA-1500 form.

Block 13 on the HCFA-1500 form is signed by the patient or insured (if patient is a
minor), this informs the insurance carrier that the patient knows the payment will be sent
directly to the provider, for all the services referenced in Block 24A – 24K of the HCFA-
1500 form.

Accepting Assignment (Do not get this term confused with assignment of benefits.)
Accepting assignment for some plans carries a high degree of liability for the provider to
abide by the rules set by the plan. When a provider “accepts assignment” from a specific
carrier such as Medicare, the provider is accepting the amount that the carrier deems
allowable for the billed services AND the provider cannot bill the insured the amount
difference of the billed charge and the allowed charge. The provider Accepting
assignment entails agreeing with many special rule and regulations set by a specific plan
or program. “Accepting assignment” will be discussed in greater detail in a later chapter
in regards to Medicare and Medicaid. Accepting Assignment is marked in Block 27 of
the HCFA-1500 form.

Authorization for certain treatments or visits, a prior authorization for the service and
approval for that service must be obtained from the payer. This is usually attached to a
document, which is used in connection with the billing to the payer. Either a numeric
entry on the HCFA-1500 claim form for electronic transmission or as a document
attached to a paper claim when mailed to the insurance carrier.

Pre-certification or Predetermination many private insurance carriers and prepaid health

plans require one or the other, before they will approve certain hospital admissions,
inpatient or outpatient surgeries and elective procedures. The carrier can refuse to pay
part or the entire fee if this requirement is not met.

Pre-certification refers to discovering whether a treatment (surgery, hospitalization, tests)

is covered under the patient’s plan.
Pre-determination means discovering the maximum dollar amount that the carrier will
pay for primary, consulting services, postoperative care, and so on.

Pre-authorization relates not only to whether a service or procedure is covered but also to
finding out whether it is medically necessary.

Coordination of Benefits is a process that occurs when two or more group plans provide
coverage on the same person. Coordination between two plans is necessary to allow for
payment of 100% of the allowed expenses, without allowing the member to ‘make’
money over and above the total cost care.

Primary plan benefit plan determines and pays its normal benefits first without regard to
the existence of any other coverage.

Secondary Plan pays after the primary plan has paid its benefits. The benefit of the
secondary plan takes into consideration the benefits and payment of the primary plan and
reduces its payment so that only 100% of allowed expenses are paid.

Basic Coding Terminology

Diagnosis: ICD-9-CM Codes ICD or International Classification of Diseases is a cluster

of codes defined to describe the symptoms and ailments of patients. Originally based on a
list of codes published by WHO (World Health Organization), this is recognized by the
US Department of Health and Human Services. ICD-9-CM refers to International
Classification of Diseases, Ninth Revision, and Clinical Modification.

ICD-9-CM codes are 3,4 or 5-digit numerical codes from 001-999.9. The three-digit code
is the parent code giving the name of the disease. The supplemental four or five digit
codes under that three-digit code are more specific. When there

are more specific codes for a particular disease, we need to use that code only. We should
use the three-digit code only where the fourth or fifth digit is not available. In addition
there are V-codes and E-codes. V Codes are Supplementary of Factors Influencing
Health Status and Contact with Health Services (V01-V82). E Codes are Supplementary
Classification of External Causes of Injury and Poisoning (E800-E999).

Procedures: CPT-4 Codes

CPT of Current Procedural Terminology is a set of codes defined to describe the
procedures / treatment rendered to the patients. Developed by the American Medical
Association, this coding system has been acknowledged by the Health Care Financing
Administration and all Insurance Carriers. This is a five digit numeric code starting from
10000-99999.

The entire set of codes from 10000-99999 is subdivided into various ranges of codes
covering various body sites / specialty of treatment such as Integumentary (Head),
Musculoskeletal, Female Genital, Male Genital, Cardiovascular, Radiology, Nuclear
Medicine etc.

HCPCS Codes are codes designed by Health Care Financing Administration Common
Procedure Coding System. They are alphanumeric codes, which are accepted by certain
limited carriers and are used in cases where no appropriate code figures in CPT-4.

ASA Codes developed by the American Society of Anesthesiologists are codes that need
to be used for anesthesia billing. The code range from 00100 through 01999.All Medicare
carriers and certain Medicaid carriers accept these codes.

RVU are Relative Value Units assigned to CPT codes for reimbursement.

Modifiers

A modifier provides the means by which the reporting physician can indicate that a
service or procedure that has been performed has been altered by some specific
circumstance but has not changed in its definition or code. The judicious application of
modifiers obviates the necessity for separate procedure listings that may describe the
modifying circumstance. Modifiers may be used to indicate to the recipient of a report
that: A service or procedure has both a professional and technical component A service or
procedure was performed by more than one physician and/or in more than one location A
service or procedure has been reduced or increased Only part of a service was performed
An adjunctive service was performed A bilateral procedure was performed A service or
procedure was provided more than once Unusual events occurred

Place of service Place of Service denoted the place where the service was rendered within
the facility. For e.g. the patient may be an inpatient or in an emergency room or in an
ambulatory surgical center. Certain carriers adopt the Medicare coding for Place of
Service while certain other have their own coding systems. For e.g. Medicare places of
service for inpatient is 21, outpatient is 22, office consultation is 11, emergency room is
23, ambulatory surgical center is 24 and so on.

Type of Service Type of Service is the specialty in which the service is rendered. For e.g.
if the specialty is anesthesia the type of service is 7, if the specialty is radiology the type
of service is 4 and so on. Enrollment

Provider Enrollment

Provider enrollment is the crux of a proper billing set up. Before we send claims to
insurance companies, we should ensure that all provider (doctors) are enrolled with the
respective carriers, all providers are contracted.

The process is as follows:

A Fresh application in Form 855 is filled and signed by the doctor and sent to the carrier.
This form should be filled up with the details such as the doctor’s name, his Social
Security Number (SSN), his State License Number, the name and address of the facility
in which he is or will be providing services, the name and address of the group of which
he has become a member, the name of the owner of the group, the pay-to address of the
group etc.

The carrier processes it and sends in intimation mentioning the provider #. This provider
# becomes the individual provider # for that doctor and needs to be stated in Box 24K
and Box 33 – PIN# in the HCFA. Box 33 of the also contains the Pay-to address where
the checks and EOBs need to be sent by the carriers. But Medicare and Medicaid do not
go by what is mentioned in the box with regard to pay-to address. Based on the pay-to
address mentioned in Form 855 at the time of enrollment the carrier records it in its
system. All checks and EOBs will be sent to this address. If there is a change of address,
the carriers need to be notified in Form 855-C. Based on this, the carriers update this
information in their system.
EDI Enrollment EDI is Electronic Data Interchange. Certain carriers have the facility to
accept claims electronically. This is mandatory requirement in the case of Federal
Carriers such as Medicare and Medicaid. This is a separate process apart from the above
Provider Enrollment process. We need to fill in a separate EDI enrollment form for
providers and send them to the carrier. The carrier will then add the provider in the EDI
database. Only then can we submit claims to that carrier for that provider electronically.
Definitions of Insurance Terms

The following are general definitions of some common insurance terms related to
insurance companies and medical insurance policies.

Claim: A claim is a request for payment from your insurance company for medical
expenses incurred due to an illness or injury covered under the terms of the policy. Each
company has requirements for how a claim is to be made; what forms must be completed
by you and your doctor(s); and what additional information, forms, or reports are
required before payment can be made. One of the biggest problems with claims made by
students is that forms are not completely filled out. This means the insurance companies
(or claim administrators) cannot pay the claim. Some insurance companies require you
provide the original bill(s) along with the claim form. You should keep photocopies of all
the documents you submit for a claim.

Covered Injury:

This is an injury that occurs while your insurance policy is in force and for which you
have received medical services, supplies or treatment after the accident. A bacterial
infection that occurs through an accidental cut or wound of from a medical or surgical
treatment of a sickness may be a covered injury.

Covered Sickness :this is a sickness which is first diagnosed or treated while your
insurance policy is in force.

Co-Insurance: The co-insurance clause requires you to pay a percentage (or a fixed dollar
amount) of your covered medical expenses. The percentage is usually expressed as
"80/20" co-insurance. This means after you have paid the deductible amount (if any) as
stated in your policy, you will pay 20% of the medical bills and the insurance company
will pay the remaining 80% of the covered medical expenses. When your total expenses
reach a dollar amount stated in your policy, the insurance company pays 100% of the
covered expenses up to the maximum benefit of your policy (from $2000 to $50,000.)

Deductible: This is the amount you pay before the insurance company pays anything.
There are two types of deductibles: an annual deductible and a per occurrence deductible.

Under an annual deductible, you will pay all expenses up to the amount of the deductible.
Once you have paid the deductible during the policy year, the insurance company will
pay for covered medical expenses for the rest of the policy year in accordance with the
terms of the policy.

Under a per occurrence deductible, you must pay the deductible amount for each separate
sickness or injury. If you have five claims in one year, you would have to pay the
deductible five times.

Co-insurance/Deductible Examples:

Example #1: Your total medical expense is $12,000. Your policy has a deductible of
$100. The co-insurance clause is 80/20 up to $5000. You must pay the $100 deductible.
Then, you will pay 20% of the $5000, or $1000. Your insurance company will pay 80%
of the $5,000, or $4,000. The insurance company will pay for 100% of the remaining
$6900 in costs.

Example #2: Your policy may state you have to pay $20 per each physician office visit.
The insurance company will pay its share of any additional expense.

Exclusions: These state the types of injuries or illnesses that are not covered. All policies
have exclusions. The most common types of exclusions are pre-existing conditions, self-
inflicted injuries, and injuries incurred while committing a criminal act. Injuries resulting
from some specific activities may also be excluded. For example, if you plan to drive a
car or snow ski, these activities may be excluded. Never assume you will always be
covered. Check the exclusions before you purchase insurance.

Health Maintenance Organization (HMO): Under this alternate type of health care, you
receive all medical services from the HMO for a pre-determined fee. If you do not use the
medical services from the HMO to which you belong, you will have to pay for your
medical care. If the HMO ceases to operate, you will also have to pay for your own
medical care. t.

Limits: All insurance policies in the USA have stated limits for the medical benefits they
will pay. They also have maximum limits for what will be paid for certain services. For
example, the policy may state limits to what it will pay for a daily hospital room, surgical
or physician fees.

Medical Evacuation and Repatriation: Evacuation means the company will pay the cost
of transporting you to a special medical facility or to your home because of a covered
medical condition. Repatriation means the insurance company will pay transportation
costs to return your remains home if you die while in the USA. These are both important
forms of coverage for cultural exchange/international students/scholars.

Necessary Treatment: This is medical or dental treatment that is (a) consistent with
generally accepted medical practice for the covered injury or covered sickness; (b) in
accordance with "approved" and generally accepted medical, surgical or dental practice
as determined by the insurance company; (c) accepted as safe, effective and reliable by a
medical specialty or board recognized by the American Board of Medical Specialties; and
(d) not "experimental or investigational" treatment as determined by the insurance
company.

Pre-existing Conditions: This refers to any medical conditions that existed before your
policy goes into effect you are to arrive in the USA on August 1 and your policy goes
into effect that day, any medical condition that existed before August 1 would not be
covered. Some policies have a waiting period (such as 6 months) after which pre-existing
conditions may be covered.

Preferred Provider Organization (PPO): This is a network of physicians, hospitals and

clinics that provide services for pre-negotiated fees. When you need medical care, you
can go to a PPO or a non-PPO provider. The insurance company will pay a greater
portion of your medical expenses if you go to the PPO.
Premium: This is the amount of money you will be required to pay for your insurance
coverage. It is generally expressed in monthly terms. You will pay the monthly premium
in US dollars for each month of coverage you purchase. If the premium is not paid, the
policy will not be in force.

Reasonable Expense: This is the reasonable and customary fee or charge for services,
supplies and treatment in the area in which they are received.

What is the difference between a participating and a nonparticipating provider?

A participating provider has signed a participation agreement with Medicare to submit

only assigned claims and follow all the regulations for assigned claims. The provider has
agreed to accept as payment the Medicare allowed amount for a given service.

A nonparticipating provider has not signed a participation agreement with Medicare and
can submit either assigned or nonassigned claims. This can be done on a claim-by-claim
basis. A nonparticipating provider must follow all the regulations that apply to the type of
claim submitted.

Medicare always be my primary insurance? Yes, unless you or your spouse are working.
If you or your spouse are still working in a company with 20 or more employees, the
employer group health plan would be the primary insurer. Medicare is also primary if you
are disabled. If you are disabled and under 65 years of age, and you or your spouse are
currently employed by a company with 100 or more employees, Medicare is secondary to
the employer group health plan.

Medicare is secondary in the following situations:

Worker’s compensation pays for a work-related injury or illness. œ Auto/liability

insurance pays claims related to an accident. œ Black Lung benefits pay claims related to
black lung illness or injury. œ In End Stage Renal Disease (ESRD) situations, Medicare
is secondary until after a coordination period; generally 30 months.

services will Medicare Part B cover

Medicare Part B pays for the cost of medically necessary doctor’s services and other
medical services and supplies. The following is a partial list of services that Medicare
Part B covers based on medical necessity: Ambulance transportation (limited benefit)
Artificial limbs and eyes Bone mass measurements Breast prostheses following a
mastectomy Colorectal cancer screening Diabetes monitoring Durable medical
equipment Flu, pneumonia and hepatitis B immunizations Mammogram screening
Mental health services Occupational therapy Outpatient hospital services Pap smear
and pelvic examination Physical therapy Physician services Prostate cancer screening
X-rays and laboratory tests

* Medicare will also pay for a limited amount of chiropractic and

podiatry services.

What are services that Medicare Part B will NOT cover? The following is a partial list of
services that Medicare Part B does not cover: Acupuncture Cosmetic surgery Most
dental care and dentures (we do not cover any dental services related to the care,
treatment, filling, removal or replacement of teeth, or of structures that directly support
the teeth) Eyeglasses (except following cataract surgery with an intraocular lens) Health
care while traveling outside of the United States Hearing aids Orthopedic shoes
Prescription drugs Routine eye care Routine foot care (in most cases) Routine or yearly
physical exams

Capitation: A method of paying medical providers through a pre-paid, flat monthly fee
for each covered person. The payment is independent of the number of services received
or the costs incurred by a provider in furnishing those services.

COBRA: The Consolidated Omnibus Budget Reconciliation Act of 1985, commonly

known as COBRA, requires group health plans with 20 or more employees to offer
continued health coverage for you and your dependents for 18 months after you leave
your job. Longer durations of continuance are available under certain circumstances. If
you opt to continue coverage, you must pay the entire premium, plus a two percent
administration charge.

Fee-for-Service: A payment system for health care where the provider is paid for each
service rendered.

Health Maintenance Organization (HMO): Prepaid health plans in which you pay a
monthly premium and the HMO covers your doctors’ visits, hospital stays, emergency
care, surgery, preventive care, checkups, lab tests, X-rays, and therapy. You must choose
a primary care physician who coordinates all of your care and makes referrals to any
specialists you might need. In an HMO, you must use the doctors, hospitals and clinics
that participate in your plan’s network.

Lifetime Limit: A cap on the benefits paid under a policy. Many policies have a lifetime
limit of $1 million, which means that the insurer agrees to cover up to $1 million in
covered services over the life of the policy.

Medical Savings Accounts (MSAs): These health insurance plans provide incentives for
individuals to replace high premium, low-deductible policies with affordable, high
deductible catastrophic coverage. Premiums for this coverage are lower and the savings
may be used to fund a tax-pre ferred medical savings account from which you can pay on
a pre-tax basis for qualified medical care and expenses, including annual deductibles
and copayments.

Out of-Pocket Maximum: The most money you will be required to pay in a year for
deductibles and coinsurance. It is a stated dollar amount set by the insurance company, in
addition to regular premiums.

Point-of-Service (POS) Plan: A type of managed care plan combining features of health
maintenance organizations (HMOs) and preferred provider organizations (PPOs), in
which individuals decide whether to go to a network provider and pay a flat dollar
copayment (say $10 for a doctor r’s visit), or to an out-of-network provider and pay a
deductible and/or a coinsurance charge.

Pre-authorization: A cost containment feature of many group medical policies whereby

the insured must contact the insurer prior to a hospitalization or surgery and receive
authorization for the service.

Pre-existing Condition: A health problem that existed before the date your insurance
became effective. Many insurance plans will not cover preexisting conditions. Some
will cover them only after a waiting period.

Premium: The amount you or your employer pays in exchange for insurance coverage.
Primary Care Physician: Under a health maintenance organization (HMO) or point-of-
service (POS) plan, usually your first contact for health care. This is often a family
physician, internist, or pediatrician. A primary care physician monitors your health, treats
most health problems, and refers you to specialists if necessary.

Provider: Any person (doctor or nurse) or institution (hospital, clinic, or laboratory) that
provides medical care.

Third-Party Payer: Any payer of health care services other than you. This can be an
insurance company, an HMO, a PPO, or the federal government.

Usual and Customary Charge: The amount a health plan will recognize for payment for a
particular medical procedure. It is typically based on what is considered "reasonable" for
that procedure in your service area.

Utilization Review: A cost control mechanism by which the appropriateness, necessity,

and quality of health care services are monitored by both insurers and employers.

Accounts Receivables:

The primary goal of the AR is to identify and collect insurance reimbursement from third
party insurance carriers. After identification, confirmation, and submission of claims to
carriers, aggressive follow-up is critical to the success of the AR Dept. Often claims are
lost, delayed or misdirected. When that happens, for whatever reason, the insurance
carrier

will assume the claim was never submitted and deny payment based on non-receipt of the
claim. At other times, carriers might underpay on submitted claims. For underpaid claims
and claims not received, proper follow-up and perseverance by AR can dramatically
improve third party collections. Effective claims follow-up can even result in payment for
claims which would otherwise be written-off.

REASONS WHY CLAIMS ARE NOT PAID

1. Lost Claims

Insurance companies handle thousands of pieces of paper every day. If an insurance

carrier claims a 95% processing rate (high for the industry) and handles 5,000 bills and
claims daily, they lose 250 bills and claims every day. Over the 260-days work year, that
means they lose 65,000 bills and claims a year. All too often, your bills and claims are
part of that loss percentage. As stated previously, the insurance carrier assumes no
responsibility for lost claims; they just assume the claims were never sent by the
provider.

2. Missing or Incorrect Information

Insurance carriers have stringent requirements for processing claims. To complicate

things even further, insurance carriers have different claim forms, different information
requirements, and different payment standards. All requisite information must be on the
claim for it to be paid. Incorrect or missing information will result in non-payment of
your claim. Experts estimate that over 30% of all claims submitted to commercial carriers
contain missing or incorrect information.

Due to the high volume of claims, insurance carriers rarely supply detailed explanations
on unpaid claims. If the AR makes no follow- up on this claim, no further action is taken,
and the claim is literally forgotten. Following-up serves as a reminder to the insurance
carrier that they have received the subject claim and payment is expected. If the carrier
does not indicate a reason for non-payment or underpayment, the AR must determine
what information is missing or incorrect.

3.Time Requirements for Filing

One of the primary reasons for timely follow-up of non-paid claims is the strict time
requirements insurance carriers place on receiving claims. Often, insurance carriers
require providers to submit claims within 30, 60 or 90 days. Submitting the claim within
that time period is usually not a problem for most Billers. In reality, however, the
insurance carrier is stating that the claim must be received and processed within these
time constraints. Again, there are many reasons why claims are not received or processed.
If you do not make timely follow-up on those unpaid claims, then insurance carriers will
often deny payment, stamping on the returned claim, "CLAIM RECEIVED AFTER
FILING DEADLINE."

4.Simple Errors
Due to stringent filing requirements imposed by insurance carriers, claims are often
denied because of simple errors. Some of the most common simple errors are:

Incorrect patient identification code Plans only pay benefits for a valid ID number.

Incomplete or incorrect dates of service Month, date and year are required.

Incorrect or missing place of service Plans accept two digits or two letters; each plan has
different preferences.

Incomplete or unrecognizable code numbers Plans install and delete codes at their own
pace; the AR must be aware of the codes the plan accepts, as well as the modifiers it uses.

Incorrect provider number Some plans may require different provider numbers.

Missing name and address of facility where services where rendered

Plans require this for medical resource monitoring

Missing plan code or group numbe Some plans require a plan code or group number.

Wrong or missing revenue code Plans require correct revenue codes.

Missing occurrence code Plans require correct occurrence codes.

SUGGESTED FOLLOW-UP METHODS

It is essential for the AR to follow-up promptly and efficiently on outstanding claims

(now accounted for as accounts receivable). Telephone and written communications are
effective ways to contact insurance carriers about outstanding accounts receivable.

1.Telephone Follow-Up

Telephone contact is the best way to obtain information about the status of outstanding
claims. Speaking with an insurance representative allows for interactive communication,
important for determining the exact requirements for payment of the outstanding claim.
Ask all the pertinent questions necessary for you to ascertain why the claim was not paid
in a timely fashion and what the insurance carrier requires to process and pay the claim.
To save time and effort when telephoning insurance companies, gather all outstanding
claims from a particular insurance company so that you can discuss them at one time.
Also, ask to speak with the insurance claims supervisor, not just a clerk. Supervisors and
others in authority can actually impact the claims payment process; clerks can usually
only give you an update on the status of your claim. Never take "No" from someone who
is not authorized to tell you "Yes."

The main disadvantages of telephone contact are the time and cost involved obtaining the
information. Many insurance companies do not have toll-free numbers for their claims
departments, and often it is difficult to reach the person who can help with a particular
claim. To reduce the time and cost associated with telephone contacts, find out if the
insurance carrier has a toll-free number and, if possible, designate one person to call each
time follow-up is done on outstanding claims from a particular carrier. That way, the
insurance company’s claims department will be familiar with your staff person, which
might lead to more successful interaction and quicker remuneration.

Additionally, a telephone call is not a tangible document that can be produced to prove
follow-up on a claim. Therefore, it is important for the MTF to keep detailed logs
documenting every telephone contact made to insurance carriers. Unless you keep a
record of your follow-ups, if the carrier does not have the means to document telephone
conversations in the electronic claim file, there is no proof of contact once the phone call
has terminated.

2. Written Follow-Up

Written follow-up provides a low-cost alternative to telephone contact. The follow-up

letter should contain all relevant claim information (including the original claim filing
date) and a copy of the original claim. This approach is very effective for claims the
insurance carrier has lost, delayed or misdirected. Because of filing requirements set by
insurance carriers, follow-up letters should be sent as soon as a reasonable period of time
has elapsed without receipt of payment from the carrier (usually 30 or 45 days). Written
follow-up letters are also effective because they give the provider proof of follow-up,
showing that there has been a good faith effort to resolve the problem. Check with your
regional or local program manager for copies of existing claim follow-up letters.

The main disadvantage of written follow-up is that it does not provide the opportunity for
feedback from the carrier. If information is missing or incorrect, the follow-up letter does
not add or correct this information. Also, there is no guarantee (unless sent with a return
receipt or faxed with confirmation) that your follow-up letter will not be lost, delayed or
misdirected.

3. Combined Approach

To counter the disadvantages of telephone and written follow-ups, a combination of

methods is the best way to ensure payment of claims. Your first attempts to follow-up
should be written; the majority of claims 30-45 days old will be paid once the first written
follow-up is received. Written follow-up should be used until the claims are 90 days past
due. If the insurance carrier has indicated that information is missing or incorrect, send
the proper information and note the date the information was sent.

Once a claim has reached the 90 days past due point and no response has been received
from the carrier, you should start telephone follow-up. Telephone contact should be
initiated on claims for which no payment or explanation of delay is received from the
carrier for 90 days. At this point, it is necessary to obtain information directly from the
carrier regarding the status of the claim. You should continue making telephone contact
on a regular basis (every 30 days) until payment is received, the claim is written-off, or
the claim is referred to the Staff Judge Advocate or Judge Advocate General (SJA/JAG)
for collection.

FOLLOW-UP SYSTEM SUGGESTIONS

1.Suspense System

In order to know when claims are outstanding for a set length of time, a suspense system
can be put in place to give notice when different follow-up actions are required. If
possible, the suspense should be initially linked to when the claim was first submitted to
the carrier. At appropriate intervals (see the schedule below), the suspense system will
indicate the need for follow-up on a particular claim.

2. Aging Report

An aging report will show the length of time a claim has been listed as an account
receivable. Divide the report into 30, 60, 90, 120 and 180 days past due intervals and
allocate the claims accordingly. Time and dollar amount are two approaches you can use
to collect accounts receivable. Under the time method, take the oldest accounts (those
over 180 days) and concentrate on them until resolved. Then concentrate on the 120 days
past due accounts, then 90 days, and so on. When approaching accounts receivable by the
dollar amount method, list the highest dollar amount claims outstanding, regardless of
time past due, and take appropriate actions depending on the length of time past due.

3. Aging Report Meeting

Each month, hold a meeting to discuss past due claims and problems the AR is
experiencing in receiving payments in a timely fashion. Give everyone an updated status
on your accounts receivable and stress the importance of the meeting to each attendee.
The exchange of ideas between individuals can generate solutions and be a very valuable
tool when exercised correctly.

CLAIM FOLLOW-UP SCHEDULE

The following schedule is recommended for written and telephone follow-up for
outstanding claims:

30 Days

Mail or fax a follow-up letter containing all relevant claim information (including
original filing date) and a copy of the original claim. Request an explanation for payment
delay and state that the original claim was filed in a timely fashion with all necessary
information contained on the claim form.

Indicate that the letter is a 30 day follow-up and additional follow-up will occur if
payment is not received promptly.

60 Days

Send a similar letter and copy of original claim as before.

Indicate that the letter is a second, 60 day follow-up and additional follow-up will occur
if payment is not received promptly.

90 Days

Begin telephone contact with the insurance carrier to determine the status of the
outstanding claim(s). Talk to a supervisor or someone with authority. Note on the
patient’s claim folder the contact date, the name of the person contacted, the claim
number, and any relevant information needed by the carrier to process and pay the claim.
Take appropriate action to speed the carrier’s claims payment process. If telephone
contact is not possible, send another letter and claim as before. Indicate that the letter is a
third, 90 day follow-up and additional follow-up will occur if payment is not received
promptly.

120 Days

Telephone contact is essential. Contact the insurance carrier as noted above. Stress that
the claim is seriously past due and good faith efforts to secure payment have failed. Take
appropriate action to speed the carrier’s claims payment process.

180 Days

Contact the insurance carrier by phone to determine delay in payment. At this point, all
required information should have been sent to the carrier. Again, stress the past due status
of the claim, determine if additional information is required and take appropriate action to
speed the carrier’s claims payment process.

Over 180 Days

Contact the carrier as often as possible, with no more than 30 days elapsing between
communications. Concentrate efforts on resolving these claims. Write-offs should only
occur if the carrier has indicated refusal (for valid reasons only) to pay the claim.

1.2.3 Employment through KPO and BPO:

BPO is from software or IT work but encompasses both voice (call center) services and
back‐office activities of varying complexity, ranging from routinized data processing to
higher order analytical workflows. The proportion of call center work declined from 65
per cent of total Indian BPO to around 50 per cent , as back‐office activity grew
disproportionately within an expanding industry (Table1). This article considers
employer perspectives on, and employee experiences of, both voice and non‐voice
segments.
Table 1. Employment in international‐facing BPO in India

Year Employment % rate of growth

2009 107,000 n/a

2010 171,000 58.8

2011 216,000 26.3

2012 316,000 46.3

2013 409,000 29.4

2014 553,000 35.2

2015 704,000 27.3

2016 738,000 4.6

2017 770,000 4.1

 CHAPTER-2
INTRODUCTION
TO
ORGANIZATION
Name of the company: brigadical meditech

Type , Public Charitable Organization

Industry Health care(BPO&KPO)

Founded January 27, 2009 at banipark, Jaipur

Founders Dr. Chennai and team

Area Worldwide
served


Key people Dr. Chennai (main doctor)
 Naresh gehlot (manager)

Gmail
Naish.brigadical.meditech@gmail.com

Services provided by the company:

Billing services: Medical Billing is the practice of submitting claims to Insurance

companies or the United States government, specifically Medicare in order to receive
payment for services provided to a patient by a doctor

The insurance review department reviews the claim and after the edit checks, the claim is
adjudicated and processed for payment. The check and the Explanation of Benefits are
sent to the provider
insurance services: Health insurance is insurance against medical expenses. Put simply,
people with health insurance, sometimes called ‘the insured’ or ‘subscribers,’ pay a
certain amount in order to have a degree of protection against medical costs.

Health insurance comes in a number of forms, including:

claim settlement services: The creation of the claim is where medical billing most
directly overlaps with medical coding. Medical billers take the procedure and diagnosis
codes used by medical coders and use them to create claims.

Procedure codes, whether Current Procedure Terminology (CPT) or Healthcare Common

Procedure Coding System (HCPCS), tell the payer what service the healthcare provider
performed. Diagnosis codes, documented using ICD codes, demonstrate medical
necessity. In other words, procedure codes tell the what of a patient’s visit, and the
diagnosis codes tell the why.

AR services:
 Chapter-3
Research methodology
 TITLE OF THE STUDY

“MEDICAL INSURANCE AND BILLING SERVICES OF BRIGADICAL MEDITECH

PVT.LTD AND PETIENT SATISFACTION OF MAYO CLYNIC

Duration of the Project - 45 days

OBJECTIVE OF THE STUDY

1. PRIME OBJECTIVE

To understand medical services and claim settlement.

2. OTHER OBJECTIVE

 To find out the patient preference according to insurance plans.

 To understand health insurance plans.

 To find out claim.

TYPE OF RESEARCH

All the findings and conclusions obtained are based on the survey done in the working
area within the time limit. I tried to select the sample representative of the whole group
during my job training. I have collected data from people linked with the organization

Research Plan:

1. Preliminary Investigation: In which data on the situation surrounding the problems

shall be gathered to arrive at the correct definition of the problem. An understanding of
its environment.

2. Exploratory Study: To determine the approximate area where the problem lies.
Research Design:

Research was initiated by examining the secondary data to gain insight into the problem.
By analyzing the secondary data, the study aim is to explore the short comings of the
present system and primary data will help to validate the analysis of secondary data
besides on unrevealing the areas which calls for improvement.

Collection of data:

.1. COLLECTION OF PRIMARY DATA

 Through manger and colleagues

 From doctors and employees of insurance company through AR calling

 Through patients

2. Secondary Data:

It was collected from internal sources. The secondary data was collected on the basis of
organizational file, official records, news papers, magazines, management books,
preserved information in the company’s database and website of the company.

Sampling Plan:

Since it is not possible to study whole universe, it becomes necessary to take sample from
the universe to know about its characteristics.

Sample Technique:

Random Sampling.
Research Instrument:

Structured Questionnaire

Limitations

Every work has its own limitation. Limitations are extent to which the process should not
exceed. Limitations of this project are:

 The project was constrained by time limit of 45 days

 . Mindset of people may very depending upon their age, gender, income etc.

 Respondents were very busy in their schedule.

So it was very time consuming for collecting information to answer all the questions
properly.
 CHAPTER- 4
DATA ANALYSIS
AND
INTERPRETATIONS
METHODS & TECHNIQUES OF DATA ANALYSIS

Data Analysis Concept

Data analysis is a practice in which raw data is ordered and organized so that useful
information can be extracted from it. The process of organizing and thinking about data is
key to understanding what the data does and does not contain. There are a variety of ways
in which people can approach data analysis, and it is notoriously easy to manipulate data
during the analysis phase to push certain conclusions or agendas. For this reason, it is
important to pay attention when data analysis is presented, and to think critically about
the data and the conclusions which were drawn. Raw data can take a variety of forms,
including measurements, survey responses, and observations. In its raw form, this
information can be incredibly useful, but also overwhelming. Over the course of the data
analysis process, the raw data is ordered in a way which will be useful. For example,
survey results may be tallied, so that people can see at a glance how many people
answered the survey, and how people responded to specific questions. In the course of
organizing the data, trends often emerge; modeling the data with the use of mathematics
and other tools can sometimes exaggerate such points of interest in the data, making them
easier for the researcher to see. Charts, graphs, and textual write-ups of data are all forms
of data analysis. These methods are designed to refine and distill the data so that readers
can glean interesting information without needing to sort through all of the data on their
own.

Data Analysis process

Once the necessary data collected, the next task is to aggregate the data in a meaningful
manner. A number of tables are prepared to bring out the main characteristics of the data.
The researcher should have a well thought out framework for processing and analyzing
data, and this should be done prior to the collection. It includes the following activities:

I. Editing

The first task in data processing is the editing. Editing is the process of examining errors
and omissions in the collected data and making necessary corrections in the same.

II. Coding
Coding is necessary to carry out the subsequent operations of tabulating and analyzing
data. If coding is not done, it will not be possible to reduce a large number of
heterogeneous data into meaningful categories with the result that the analysis of data
would be weak and ineffective, and without proper focus.

III. Tabulation

Tabulation comprises sorting of the data into different categories and counting the
number of cases that belong to each category. This is also called universal tabulation. The
analysis based on just one variable is obviously meager. Where two or more variables are
involved in tabulation, it is called vicariate or multivariate tabulation.

IV. Analysis

After the all three above steps, the most important step is analysis of the data
Questions asked from billing assistant & AR caller-

1. Have your billing process done?

Options Respondents

Yes 7

No 3

yes
no

Interpretation: It shows 7 of respondent out if surveyed have done their billing process
and other 30% said they not .
2. Have you called the doctor?

Options Respondents

Yes 7

No 3

yes
no

Interpretation: It shows 7 of respondent out if surveyed have called the doctor and
other 30% said they not .
3. Have you called to insurance company?

Options Respondents

Yes 8

No 2

yes
no

Interpretation: It shows 7 of respondent out if surveyed have called to insurance

company and other 3 said they not .
4. Have you collect all the information of patient?

Options Respondents

Yes 70

No 30

yes
no

Interpretation: It shows 7 of respondent out if surveyed have collected the information

from patient and other 3 said they not .
Questions asked from patient-

5. Will Medicare always be your first insurance?

Options Respondents

Yes 60

No 30

Sometimes 10

10

yes
30 no
sometimes
60

Interpretation:
6. Did you get to know about mayo hospital?

Options Respondents

On Television 40

On Newspaper 30

On Magazine 10

On Internet 10

On Other 10

10

10
on tv
40
on newspaper
10 on magzine
on internet
on others

30

INTREPRETAION:

It shows that 40% respondents out of surveyed population said that they saw the
advertisement first on the Television, 30% said Newspaper, 10% said Magazines, 10%
saw this on Internet and rest saw the ad on other media sources.
7. How is the advertising of mayo hospital?

Options Respondents

Good 70

Bad 10

Average 10

10

10
good
bad
average

70

INTERPRETATION:

IT shows that 80% respondents out of surveyed population said that the advertising of
mayo hospital is good, 10%said its is not good and 10%said that its average .
8. How clean the hospital please rate?

Options Respondents

1* 5

2* 10

3* 15

4* 20

5* 50

Series 1
60

50

40

30
Series 1

20

10

0
1* 2* 3* 4* 5*

INTERPRETATION:

It shows that 50% respondents out of surveyed population rated 5* to mayo hospital,30%
rates 4*, 15% rated 3* and 10% rated 2* and others rated as1*
9. How was the doctor’s service?

Options Respondents

Good 90

Bad 10

10

good
bad

90

INTERPRETATION:

It shows 90% of respondent out if surveyed said the service of doctor is good and other
10% said not good
10. How was the after treatment services?

Options Respondents

Good 70

Bad 10

Average 20

20

good
10 bad
average

70

INTERPRETATION:

It shows 70% of respondent out if surveyed said the after treatment service of is good
and other 10% said not good and 20% said average
11. Are you satisfied with the charges?

Options Respondents

Yes 70

No 30

30

yes
no

70

INTERPERTATION;

It shows 70% of respondent out if surveyed are satisfied with service and other 30%
said they not .
12. do you have insurance ?

Options Respondents

Yes 90

No 10

10

yes
no

90

INTERPRITATION:

It shows 90% of respondent out if surveyed said they have insurance and other 10% said
have not.
13. Claim billed by hospital to your insurance company was accordingly to your
treatment?

Options Respondents

Yes 70

No 30

30

yes
no

70

INTERPRETATION:

It shows 70% of respondent out if surveyed said the claim billed accordingly their
treatment and other 30% said not .
14. Do you have your insurance card?

Options Respondents

Yes 70

No 30

30

yes
no

70

INTERPRETATION:

It shows 70% of respondent out if surveyed said they have their insurance and other 30%
said they have not.
15. Do you have your insurance card?

Options Respondents

Good 50

Bad 15

Rude 10

Average 25

25

good
bad
50
rude
10 average

15

INTREPRETATION:

It shows 50% of respondent out if surveyed said they have the staff of mayo hospital is
good 15% said not good ,10% said rude and others 25% said its average
16. What you feel about the charges ? it was-

Options Respondents

Higher 30

Appropriate 70

30

higher
appropriate

70

INTERPRETATION:

It shows 70% of respondent out if surveyed said fee is apocopate and other 30% said
that its high
17. Will you recommend to others ?

Options Respondents

Yes 95

No 5

yes
no

95

INTERPRETATION:

It shows 95% of respondent out if surveyed said they will recommend to other and other
5% won’t
CHAPTER-5
FINDINGS
Conclusion:
In USA it is mandatory for everyone to have an insurance. Doctor gives treatment to the
patient and then billed the charges to the patient's insurance company. Then insurance
company review the claim and then pay to the doctor. In between several steps involved
which we have described in detail in the report. This is just an broad overview. This kind
of policy help every citizen of the country by distributing the cost of high treatments and
medical bills. Just by paying little amount of premium individual are covered for big risk.
Also we have discussed the every kind of bills which need doctor or hospital bill to the
insurance companies.

The health care industry in USA , which reaches millions of beneficiaries and expends
about a trillion dollars annually, is constantly evolving. In particular, the billing process
has changed dramatically in recent years. As a result, the time is right for billing
companies to implement strong, voluntary compliance programs. As stated throughout
this guidance, compliance is a dynamic process that helps to ensure billing companies are
better able to fulfill their commitment to ethical behavior and to meet the changes and
challenges being imposed upon them by Congress and private insurers. Ultimately, it is
OIG’s hope that voluntarily created compliance programs will enable billing companies
to meet their goals and substantially reduce fraud, waste and abuse, as well as the cost of
health care to Federal, State and private health insurers.
Recommendation &Suggestion:

1. Train Staff to Collect

Collections start with your front desk staff so it’s critical they have been trained to get
that cash before the patient sees you. Make sure there are signs up around your waiting
room clearly stating your payment policy. When any member of your staff contacts
patients to confirm an upcoming appointment, they should mention any balance that
patient may be carrying as well as explain the various payment options available. And,
make sure to have staff make it crystal clear that they are expected to pay that balance
before their next appointment or when they arrive at the office.

Also, provide staff with scripts they can use to deal with overdue accounts and let them
know they should always be respectful and courteous, no matter how many times they are
forced to make contact about unpaid bills.

2. Be Transparent About Your Prices

One of the main reasons providers have a hard time with their medical billing collections
is because patients are completely blindsided by costs and have not budgeted for the
expense. Always be transparent and tell your patients exactly what procedures cost so
they will know whether they can afford them or not.
Also be sure to check their coverage before their appointment so you can factor all costs
into the discussion and remind those patients with high-deductible plans that they will
most likely be paying out of pocket.

3. Select Powerful Medical Billing Software

If you haven’t yet purchased medical billing software, you’re making things far more
difficult than they need to be, unless you like uphill battles.

Practice management and medical billing software’s can streamline your entire
collections process by tracking past due bills, identifying those patients who have fallen
behind, and automating late fees. A robust solution may come with a bigger price tag but
remember, that software will end up saving you a ton on internal billing resources as well
as increase your collection rate.

4. Offer Different Payment Options

No doubt most of your patients have every desire and intention to pay, they just don’t
currently have the financial means to. Consider offering different payment options to
those patients who have larger outstanding bills and can’t pay the full amount all at once.

Options include a payment plan, interest-only payments, deferral, etc.

5. Make Paying Easy

It should be fairly obvious – if you want your patients to pay their bills, you must make it
as easy as possible. For instance, your collections will increase if you let patients pay you
online with a credit or debit card. Another bonus for allowing your patients to use online
bill pay is that you will entice more patients to use your patient portal which will
ultimately help you satisfy meaningful use requirements – a win/win.

6. Incentivize Your Billing Staff

Recognize that it’s not a lot of fun for your billing staff to have to call patients day in and
day out to collect on past-due accounts. It can be frustrating and tiring, and some staff
members could eventually become unmotivated. Always show staff your appreciation
and offer an incentive program that will keep them motivated.

7. Be a Squeaky Wheel

Being a squeaky wheel generally gets you what you want, even when it comes to
collecting from your patients. It’s standard to contact patients on a monthly basis, but if
your staff can handle it, why not make contact once a week. Regular and persistent
contact may convince a good portion of your patients that it is, in fact, time to pay up.

8. Use USPS Address Service

Good luck collecting from patients who have relocated without providing you with a new
address. For a small fee you can add “address service requested” to any bills you
physically mail so the post office will send you the patient’s correct address.

9. Track and Manage Your Results

You’ll never be able to improve your medical billing collections if you don’t track and
manage your results. Make it a habit and priority to review your collections every month
during your financial meeting to see which methods and processes are working and
which aren’t.

10. Know When It’s Time to Partner with a Medical Billing Vendor
Chances are many of your unpaid invoices eventually get sent to a third-party collection
agency that takes a percentage of the payment anyway, you may want to eventually
consider using a third-party medical billing vendor who will work on your behalf and get
you paid from everyone who owes you money. This will allow your staff to focus on the
other day-to-day tasks, let you focus on your patients, all while increasing your revenue.

You don’t need to put all of these 10 tips into place in order to see an increase in
collections. In fact, not all of these strategies are right for every practice, so be sure to test
and track each to see which gives your revenue a boost.
ANNEXURE
BIBLIOGRAPHY

 Medical Billing and Coding For Dummies By Karen Smiley

 Insurance for Dummies By Jack Hungelmann
 Health Insurance By IntroBooks
 American Medical Association Family Medical Guide By American Medical
Association

WEBLIOGRAPHY

 https://capturebilling.com/5-tips-to-improve-medical-billing/
 https://www.enter.health/healthcare-billing
 https://www.mplans.com/medical_billing_service_marketing_plan/situation_anal
ysis_fc.php
 https://images.template.net/wp-content/uploads/2016/01/18124139/SWOT-
Analysis-Healthcare-
 QUESTIONNAIR

1) Have your billing process done?

a) Yes
b) no

2) Have your billing process done?

a) Yes
b) no

3) Have you called the doctor?

a) Yes
b) no

4) Have you called to insurance company?

a) Yes
b) no

5) Will medical insurance always be your first insurance?

a) Yes
b) No
c) Sometimes

6) How did you get to know about mayo hospital?

a) On Television
b) On Newspaper
c) On Magazine
d) On internet
e) On others
7) How is the advertising of mayo hospital?

a) Good
b) Bad
c) Average

8) How clean the hospital please rate?

a) 1*
b) 2*
c) 3*
d) 4*
e) 5*

9) How was the doctor’s service?

a) Good
b) Bad

10) How was the after treatment services?

a) Good
b) Bad
c) Average

11) Are you satisfied with the charges?

a) Yes
b) No
12) Do you have insurance?

a) Yes
b) No

13) Claim billed by hospital to your insurance company was accordingly to your
treatment?

a) Yes
b) No

14) Do you have your insurance card?

a) Yes
b) No

15) Do you have your insurance card?

a) Good
b) Bad
c) Rude
d) Average

16) What you feel about the charges? it was-

a) Higher
b) Appropriate

17) Will you recommend to others?

a) Yes
b) No